306005794-6-10-2021-22-AS-JTIE-C3UN8F-20210610101414

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005794
Report Date: 05/07/2020
Date Signed: 06/10/2021 10:14:19 AM

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:	JC HOME FOR SENIORS - THOR		FACILITY NUMBER:	306005794
ADMINISTRATOR:	EMETERIO-PARUNGAO, MARIA		FACILITY TYPE:	740
ADDRESS:	6002 THOR DR.		TELEPHONE:	(714) 369-5003
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY:	6	CENSUS: 0	DATE:	05/07/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Maria Emeterio and Jeremy Parungao		TIME COMPLETED:	12:40 PM

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 (LPA) Jenifer Tirre and Kimberly Lyman contacted the facility via telephone to conduct a pre-licensing visit via FaceTime due to COVID-19 and pre-cautionary measures. LPA's identified themselves and discussed the purpose of the call with Licensee/Administrator Maria Emeterio. Administrator Jeremy Parungao was present as well. An initial application to operate a Residential Facility for the Elderly was received by CCL on 04/17/2020 for a capacity of 5 non-ambulatory residents and 1 bedridden resident. There are 0 residents in care during today's visit. LPA Tirre, and LPA Lyman along with Administrators Emeterio and Parungao toured the facility via FaceTime at 10:07 AM and observed the following: Structure: Facility is a one story, 5 bedroom, 2 bathroom house with an attached garage and a peach exterior. The exit gates are closed unlocked, and self latching. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: 4 of 5 rooms are equipped with appropriate lighting, dresser, and ample closet space. All exit doors are equipped with operational auditory exit alarms. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Linen supply is in ample supply for residents in care. Emergency Phone Numbers and Exit Plan: Available for review in common area of the facility. Food Service: Facility to obtain 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, prior to admitting residents. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Fire extinguishers are mounted and charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins: Locked/stored in secured cabinet inside garage. Water Temperature: Tested and recorded between 108.2 and 109.9 degrees F. in facility bathrooms. Reading Material Games, and Equipment: LPA's observed games, puzzles and coloring books. Due to COVID-19, there are no group activities scheduled at this time. CONT ON LIC 809C DATED 05/07/2020.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2020

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JC HOME FOR SENIORS - THOR	FACILITY NUMBER: 306005794
	VISIT DATE: 05/07/2020

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Medications, First-Aid Kit & Book: First aid kit observed contained most of required items including tweezers and scissors. LPA's observed completed emergency disaster plan. Medication is stored and locked in the facility. Kitchen sharps also locked inside Medication cabinet. Backyard: LPA observed a clean safe backyard with ample shaded seating. Fire Clearance: Approved for 5 non-ambulatory residents and 1 bedridden resident on 04/16/2020.

The facility is ready to be licensed. Component III was waived due to Licensee operating multiple facilities.

Licensee to correct the following items:

Let us know poster needs to be proper size of 20x22, proper posters in restrooms for hand washing procedures, and entry posters outside upon admitting residents.
Private room #2 needs dresser
First-Aid Kit needs First-Aid manual and thermometer.

Licensee to obtain emergency food and water supply upon admission of residents.

An exit interview was conducted with Administrator Emeterio via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2020

LIC809 (FAS) - (06/04)

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