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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005869
Report Date: 09/02/2022
Date Signed: 09/02/2022 01:40:19 PM


Document Has Been Signed on 09/02/2022 01:40 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: 6DATE:
09/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Simona Aziza, AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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On 09/02/2022, Licensing Program Analyst conducted an unannounced inspection for the purpose of conducting a case management visit.

LPA arrived at the same time as EMT and the Fire Department who were present to assist with and assess the medical status of resident R1 after resident was observed having a fainting episode by the caregivers. Caregivers had both interrupted the breakfast service in order to attend to the ongoing medical emergency.

Upon entering the facility, Licensing Program Analyst observed that the pre-poured medication for resident R2 was left in a container on the dining room table and was left unattended for approximately 25 minutes. Photographic documentation of the observation was collected by LPA. None of the residents, all non-ambulatory, were observed in the room during that duration of time. During the duration of the visit, all residents were observed to be relaxing in their bedrooms and appear clean and well taken care of.

Based on the observations made during today's visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights 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: 09/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/02/2022 01:40 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: JJ ASSISTANCE HOME CARE
FACILITY NUMBER: 306005869

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2022
Section Cited

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The California Code of Regulations Section 87465(h)(2) indicates that (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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LPA observed pre-poured medication on the dining room table as both members of staff had left the room to tend to an emergency. This constitutes a potential risk to the health and safety of individuals in care.
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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: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 09/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2