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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005869
Report Date: 04/12/2022
Date Signed: 04/12/2022 04:50:20 PM


Document Has Been Signed on 04/12/2022 04:50 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:JJ ASSISTANCE HOME CAREFACILITY NUMBER:
306005869
ADMINISTRATOR:AZIZA, SIMONAFACILITY TYPE:
740
ADDRESS:23712 CORONEL DRTELEPHONE:
(949) 587-1595
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 4DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Henry Magbiray, caregiver
Aurora Magbiray, caregiver
Simona Aziza, Administrator
TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by Henry Magbiray, caregiver after explaining the purpose of the visit. Licensee Simona Aziza was notified by phone and arrived later to assist with the visit.

At approximately 4:10pm, LPA accompanied by administrator toured the inside and outside of the facility. There are currently four (4) residents in care. The residents are observed to be relaxing in their bedrooms and appears well taken care of. The bedrooms include all necessary components. Bathrooms are equipped with grab bars and slip mats. Facility appears to be clean, sanitary and free of odors in all areas inspected. Staff present is observed to be correctly associated in Guardian.

Sharp instruments are kept in a cabinet secured by a magnetic lock. Cleaning supplies and toxic substances are securely stored in the kitchen as well. LPA observed the facility has COVID-19 Precautions posters and required department postings. Facility has an adequate supply of PPE. A LIC808 Mitigation Plan has been submitted on 07/08/2021.

LPA observed a sufficient supply of food and water. A 30-day supply of medication is centrally stored and locked in a cabinet. LPA toured the outside of the facility. Outdoor furniture is present for the residents' enjoyment in the backyard. The perimeter gates are self-latching and can easily be opened in an evacuation.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Two Technical Advisories are however issued in regard to the prescription for half-rails as well as storage rules for cleaning supplies. This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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