<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005682
Report Date: 05/16/2024
Date Signed: 05/16/2024 10:33:51 AM

Document Has Been Signed on 05/16/2024 10:33 AM - 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:
05/16/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:38 AM
MET WITH:Staff on duty - Shantae FernandezTIME VISIT/
INSPECTION COMPLETED:
10:56 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Celine De Perio and Rose Ruppert made an unannounced visit to conduct a case management visit in conjunction with a complaint: 22-AS-20240214151712. LPAs explained reason for visit and were greeted and granted entry by staff on duty (S1) Shantae Fernandez.

During the course of the investigation that took place on 2/21/24 and 5/9/24, it was discovered that there is an individual living at the facility who is violating the rights of the clients by not according them dignity and respect. It was also discovered that the individual residing at the facility is not an active staff member.

Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with S1 Fernandez.

A copy of this report and appeal rights were provide and explained.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 05/16/2024 10:33 AM - It Cannot Be Edited


Created By: Celine DePerio On 05/16/2024 at 10:09 AM
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: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2024
Section Cited
CCR
80072(a)(1)

1
2
3
4
5
6
7
80072 Personal Rights
(a) Each client shall have personal rights which include, but are not limited to, the following:
(1) To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
As a plan of correction (POC), licensee will formulate a plan on how to ensure the rights of the clients will be respected. Licensee will provide proof of POC to LPA on or by 5/23/24.
8
9
10
11
12
13
14
Based of LPAs interviews, observations, and documentation review, there is an individual residing at the facility, who will yell at the clients and make threats. This individual is background cleared, however is not an active staff member at the facility.
This poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Sheila Santos
LICENSING EVALUATOR NAME:Celine DePerio
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2