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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005794
Report Date: 05/12/2025
Date Signed: 05/12/2025 11:14:00 AM

Document Has Been Signed on 05/12/2025 11:14 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:JC HOME FOR SENIORS - THORFACILITY NUMBER:
306005794
ADMINISTRATOR/
DIRECTOR:		EMETERIO-PARUNGAO, MARIAFACILITY TYPE:
740
ADDRESS:6002 THOR DR.TELEPHONE:
(714) 369-5003
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
05/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:34 AM
MET WITH:Jay ParungaoTIME VISIT/
INSPECTION COMPLETED:
12:03 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced annual inspection visit at the facility. Upon arrival, LPA Haddadin was greeted by Administrator (AD) Jay Parungao, who granted access to the premises. LPA Haddadin explained the purpose of the visit.
LPA Haddadin, accompanied by AD Parungao, toured the interior and exterior portions of the facility. The following observations were made:
The facility is a single-story residence featuring four (4) resident bedrooms, two (2) bathrooms, a staff room, a kitchen, a dining room, a living room, and an attached garage. At the time of the visit, three (3) residents were present and were observed relaxing in their respective rooms.
Resident bedrooms were furnished with beds, chairs, clean linens, and adequate storage space. All rooms were free of tripping hazards. Manual smoke detectors, carbon monoxide detectors, and exit alarms were tested and confirmed to be operational. The bathrooms were observed to be in good repair and equipped with grab bars. The hot water temperature was measured at 115.3∘F. The facility met the minimum food stock requirements, maintaining a two-day supply of perishable items and a seven-day supply of non-perishable items.
A fire extinguisher was observed with a stated purchase date of August 29, 2024.
The exterior portion of the facility included outdoor furniture in good condition. The grounds were free of tripping hazards and provided ample space for activities.
The kitchen was found to be in good repair. Cleaning supplies and sharp items were stored in a manner that made them inaccessible to residents in care. Medications were stored securely in a locked location in the hallway.
Alisa OrtizTELEPHONE: (714) 703-2855
Samer HaddadinTELEPHONE: (714) 790-2096
DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JC HOME FOR SENIORS - THOR
FACILITY NUMBER: 306005794
VISIT DATE: 05/12/2025
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LPA Haddadin reviewed the files and medications for two (2) clients; no discrepancies were noted. A review of two (2) staff files also revealed no discrepancies. All staff and client files contained all required documentation.
Upon review of facility records, it was noted that documentation for the required quarterly fire drill was not on file.
No other deficiencies were noted during today's inspection visit.
An exit interview was conducted with AD Parungao, and a copy of this report was provided
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer HaddadinTELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC809 (FAS) - (06/04)
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