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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005682
Report Date: 11/12/2024
Date Signed: 11/12/2024 05:17:03 PM

Document Has Been Signed on 11/12/2024 05:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOUSEFACILITY NUMBER:
306005682
ADMINISTRATOR/
DIRECTOR:		GILBERT MARQUEZFACILITY TYPE:
735
ADDRESS:14741 HOLT AVETELEPHONE:
(714) 923-1221
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 4CENSUS: 4DATE:
11/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Tiffany McclaryTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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Licensing Program Analysts (LPAs) Samer Haddadin and Fred Arias along with Licensing Program Manager (LPM) Alisa Ortiz conducted an unannounced visit for the purpose of completing an annual required inspection. LPAs, LPM were greeted and granted entry by Tiffany McClary and explained the nature of the visit. James Rock, Administrator (AD), along with Assistant Administrator Shantae Fernandez arrived shortly after and met with LPA.

LPAs/LPM accompanied with lead staff began the tour of the inside and outside of the facility. Facility is a 6 bedroom, 3 bathroom, single story home with an attached garage.

LPAs/ LPM observed required Department postings posted on the wall of facility. Facility stays within the capacity limitations of 4. At the time of visit, the facility had 4 clients in care.

Also observed minimum of one week of non-perishables foods and two days of perishables foods available. There is additional food storage in the spare refrigerator and pantry located in garage.

LPAs/LPM reviewed medication and observed medication was labeled and stored inaccessible to clients in care. Also inspected the bathroom and measured the hot water temperature which measured between 112 to 118 degrees Fahrenheit. LPA observed a fire extinguisher with service date of September 15th, 2024, in the kitchen and in hallway. Fire drills conducted quarterly, and last Fire Drill was conducted on September 21, 2024.

All bathrooms were observed to have a supply of soap, toilet paper and towels. The facility was equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants were stored locked in the garage and inaccessible to clients in care and away from food. (CONTINUE 809C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/12/2024
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The facility has an available clean supply of linens. LPAs/LPM inspected client’s bedrooms which have sufficient lighting to ensure safety and comfort. All bedrooms were observed to have all required components. Storage space is provided for clients in their bedroom. Smoke detectors were tested and found to be operational throughout the facility.

LPAs/LPM toured the outside of the facility and observed outdoor passageways were free of obstructions and or tripping hazards. LPA observed there was shaded seating areas for client’s enjoyment.

LPAs/LPM reviewed 4 clients’ records. All the required documentation was present and current in the client’s files. The facility P&I records had discrepancies. LPA observed that an individual log is maintained for each client. LPAs/LPM reviewed 3 employee records and observed records that were reviewed had a current First Aid certificate, and staff files had all required documentations.



Based on today’s visit and the observations made today, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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