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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005682
Report Date: 02/21/2024
Date Signed: 02/21/2024 03:21:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/12/2024 and conducted by Evaluator Celine DePerio
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240212113711
FACILITY NAME:JEAN'S HOUSEFACILITY NUMBER:
306005682
ADMINISTRATOR:GILBERT MARQUEZFACILITY TYPE:
735
ADDRESS:14741 HOLT AVETELEPHONE:
(714) 923-1221
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:4CENSUS: 4DATE:
02/21/2024
UNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Executive Director - Stan Smith TIME COMPLETED:
02:25 PM
ALLEGATION(S):
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9
Licensee does not ensure that staff providing care to residents are associated to the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced 10-day visit to the facility and to deliver the findings. LPA De Perio explained the purpose of today's visit, was greeted, and granted entry by executive director (ED) Stan Smith.

During the investigation, LPA De Perio toured the physical plant of the facility, conducted interviews, and requested copies of pertinent records reviewed.

During this visit, LPA De Perio observed a total of three staff on duty. Per record review, LPA De Perio verified that the staff on duty staff 1 (S1) and staff 2 (S2) are background cleared, however are not associated to the facility via Guardian. LPA De Perio reviewed the facility LIC500, and was provided with a direct admission from ED Smith confirming that staff 4 (S4), staff 5 (S5), staff 6 (S6), staff 7 (S7), staff 8 (S8) and staff 9 (S9) are background cleared, however have not been associated to the facility via Guardian.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 22-AS-20240212113711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JEAN'S HOUSE
FACILITY NUMBER: 306005682
VISIT DATE: 02/21/2024
NARRATIVE
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Based on LPA’s interviews which were conducted, review of documents obtained, and observations, the preponderance of evidence standard has been met, therefore the allegation is SUBSTANTIATED.

For this visit, citations were issued - a civil penalty was assessed and issued.

An exit interview was conducted with ED Smith.

A copy of this report was explained, and appeal rights were provided during the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240212113711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JEAN'S HOUSE
FACILITY NUMBER: 306005682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2024
Section Cited
CCR
80019(a)
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80019 Criminal Record Clearance
(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code Section 1522(b)...
This requirement is not met as evidence by:
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As plan of correction (POC) licensee will associate all 9 staff members via Guardian on or by 2/22/24.
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Based on observations, record review and interviews there are a total of 9 staff cleared and working at the facility, however per Guardian, all 9 staff members are not associated.
This poses an immediate health and safety risk to clients in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5