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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005682
Report Date: 03/08/2024
Date Signed: 03/08/2024 04:30:06 PM

Document Has Been Signed on 03/08/2024 04:30 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Amy Blackburn - Administrator TIME COMPLETED:
04:00 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a case management visit in conjunction with a complaint investigation for complaint control #22-AS-20240131154808.

During the initial complaint visit on 02/06/2024 LPA Mendivil requested the following documents: LIC 501 Personnel Record, LIC 508 Criminal Record Statement, clearance document to be sent to LPA by COB on 02/09/2024. As of 03/07/2024 the only requested document received was an incomplete LIC 501 Personnel Record for Staff 1 (S1). It was reported by Administrator that "It was our understanding that the LIC 508 is no longer required and hasn't been for a year now”

LPA Mendivil consulted with current Administrator of the importance of having documents available for CCLD to review.

Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights were provided.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/08/2024 04:30 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 03/08/2024 at 03:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 B
03/14/2024
Section Cited
CCR
80066(c)

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(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement was met as evidence by facility did not provide LPA with requested personnel records. This poses a potential risk to persons in care.
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Administrator agreed to make duplicates personnel documents and retain copies at faciltiy. Administrator to provide proof to LPA by POC due date.
Type B
03/14/2024
Section Cited
CCR
80019(d)

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80019 Criminal Record Clearance
(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.
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Current Administrator has LIC 508 and interim ED is no longer working at the facility.
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This requirement was not met as evidence by Interim ED did not have a completed LIC 508. This poses a risk 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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