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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005794
Report Date: 05/27/2021
Date Signed: 06/10/2021 10:12:36 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 - THORFACILITY NUMBER:
306005794
ADMINISTRATOR:EMETERIO-PARUNGAO, MARIAFACILITY TYPE:
740
ADDRESS:6002 THOR DR.TELEPHONE:
(714) 369-5003
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 5DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Administrator, Maria Emeterio- ParungaoTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Maria Emetrio-Parungao toured facility with LPA Tirre.

During the visit LPA toured the facility. Facility is a 5 bedroom and 2 bathroom single story home. There are 5 Residents in care. LPA observed proper covid signage at front entrance of facility as well as sanitization station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring 2022. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper and paper towels. LPA observed an outside visitation area with ample seating and shading. Residents were observed relaxing in the Living room watching TV. Facility has audible alarm system and smoke detectors. Facility has 1 fire extinguisher updated as of 07/13/20. Facility has ample emergency food and water supply. Facility water temperature was at 105.4 degrees F. Facility has required Emergency Disaster Plan posted inside facility. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with Administrator regarding the importance of maintaining a thirty day supply of PPE onsite.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator Maria Emeterio-Parungao and a copy of this report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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