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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005794
Report Date: 08/29/2024
Date Signed: 08/29/2024 12:09:25 PM


Document Has Been Signed on 08/29/2024 12:09 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: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: 4DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Maria Emeterio-ParungaoTIME COMPLETED:
12:15 PM
NARRATIVE
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On 8/29/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA was greeted and granted entry by Caregiver, Noel Mallari and who was informed of the purpose of the visit. Administrator, Maria Emeterio-Parungao arrived during the visit and was also informed of the purpose of LPA's visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents, of which one (1) may be bedridden.

LPA toured the facility with Caregiver Mallari and observed the facility is made up of a one-story home with four (4) resident bedrooms, two (2) bathrooms, a staff room, kitchen, dining room, living room and attached garage. During the tour, Caregiver Mallari tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. There were no bodies of water observed on the premises. Medications are secured in a locked hallway closet. Resident bedrooms had the required furniture and lighting. Bathrooms had grab bars near the toilets and in the showers. The facility had a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Resident files reviewed had signed admission agreements and physician's reports. Staff present have a criminal record clearance and valid first aid/CPR certification.

During the tour, LPA observed the facility had one (1) fire extinguisher mounted near the kitchen that was labeled with a green tag noting it was last serviced on 7/13/2020. LPA observed the fire extinguisher's pressure gauge needle to the left of the green zone and in the red zone, meaning the extinguisher is undercharged, warrants a recharge, and may not have enough pressure to work properly. Administrator Emeterio-Parungao reported the facility did not have another extinguisher available at that moment. LPA issued a deficiency. An exit interview was conducted where this report was reviewed and provided to Administrator Emeterio-Parungao along with an LIC809-D and appeal rights.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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 08/29/2024 12:09 PM - It Cannot Be Edited

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: JC HOME FOR SENIORS - THOR
FACILITY NUMBER: 306005794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed the facility's fire extinguisher's pressure gauge needle to the left of the green zone and in the red zone, meaning the extinguisher is undercharged, warrants a recharge and may not have enough pressure to work properly, which poses an immediate health, safety or personal rights risk to persons in care. Administrator reported they did not have an additional fire extinguisher readily available.
POC Due Date: 08/30/2024
Plan of Correction
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During LPA's visit, Administrator had facility staff go to the store and purchase a new fire extinguisher. LPA observed staff arrive with a new fire extinguisher that was immediately mounted near the kitchen. POC met.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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