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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005794
Report Date: 05/27/2022
Date Signed: 05/27/2022 03:24:59 PM


Document Has Been Signed on 05/27/2022 03:24 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: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:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Caregiver Ed MercedTIME COMPLETED:
03:45 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 by staff and explained the reason for the visit.

During the visit LPA toured the facility with Caregiver Ed Merced. Facility is a 5 bedroom (4resident rooms, 1 staff room) 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 temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring 8/15/2022. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained a working wash basin, 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 listening to music and relaxing inside bedrooms. Facility has audible alarm system and smoke detectors. Facility has 1 fire extinguisher which is fully charged. Facility has emergency food and water supply. Facility has 2 fridges and pantry with ample food supply. Facility has required Emergency Disaster Plan posted inside facility. Facility has a secured location for resident medication and files. Residents have a 30 day supply of medications. Facility has a secured location for toxins and hazardous supplies. LPA reviewed resident files. LPA observed 5 of 5 resident files. Resident files have updated Emergency contact info and Physician's reports.


No deficiencies noted during todays visit. An exit interview was conducted with Caregiver Ed Merced 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: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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