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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005682
Report Date: 03/08/2024
Date Signed: 03/08/2024 04:33:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/31/2024 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240131154808

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:
03/08/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Jacob Austin - Direct Support Professional TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Licensee did not ensure facility has a qualified Administrator
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility by Jacob Austin and explained the reason for the visit.
The Department received a complaint on 01/31/2024 and LPA Mendivil conducted an initial visit on 02/06/2024. During the initial visit LPA Mendivil requested the following documents: LIC 501, LIC 508 and clearance records for Interim Executive Director (ED) Stan Smith to be sent to LPA Mendivil by close of business on 02/09/2024. Regarding the allegation Licensee did not ensure facility has a qualified Administrator, the investigation revealed the following:

During LPA Mendivil’s initial visit on 02/06/2024 the interim ED was not available, and the listed Administrator Amy Blackburn was on leave. Per communication received via email on 03/07/2024 Administrator Amy Blackburn has since returned from leave. Based on communication received from Administrator Amy Blackburn, Interim ED has not had a TB/Health Screening completed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 22-AS-20240131154808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JEAN'S HOUSE
FACILITY NUMBER: 306005682
VISIT DATE: 03/08/2024
NARRATIVE
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Administrator Amy also stated that ’It was our understanding that the LIC 508 is no longer required and hasn't been for a year now” and was only able to provide an incomplete LIC 501 Personnel Record for ED Stan Smith.

Therefore based on the preponderance of evidence through records reviewed and communications the allegation licensee did not ensure facility has a qualified Administrator is determined to be SUBSTANTIATED,meaning the complaint allegation is valid and that a violation has occurred.


The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview was conducted and a copy of this report and appeal rights were provided to the facility representative.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20240131154808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: JEAN'S HOUSE
FACILITY NUMBER: 306005682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2024
Section Cited
CCR
85064(f)
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(f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065...
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Administrator Amy Blackburn has returned as Administrator as of 03/06/2024 and has a valid Administrator certificate expiring on 02/06/2025.
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This requirement was not met as evidence by Interim Executive Director did not meet the qualifications of 80065. This poses an immediate health and safety risk to persons in care.
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Type A
03/11/2024
Section Cited
CCR
80065(g)(1)
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(g) All personnel, including the licensee, administrator and volunteers, shall be in good health...(1)... good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior ...
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Administrator stated Interim ED is no longer working for the facility. Current Administrator to provide LPA with health screening documents.
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...to or seven days after employment or licensure
This requirement was not met as evidence Interim ED did not have a completed health screening. This poses an immediate health and safety risks to persons 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5