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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005869
Report Date: 11/08/2022
Date Signed: 11/08/2022 12:54:14 PM


Document Has Been Signed on 11/08/2022 12:54 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:
11/08/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Henry Magbiray, caregiver
Aurora Magbiray, caregiver
Simona Aziz, administrator
TIME COMPLETED:
01:15 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unnanounced visit to the facility for the purpose of following up on the plan of corrections for deficiencies observed during a case management visit and a complaint investigation visit both conducted on 09/02/2022. LPA was greeted and granted entry by the facility's caregiving staff and explained the purpose of the visit. Administrator Simona Aziz was notified of the visit by voicemail and arrived later to assist with the visit.

During the case management visit on 09/02/2022, LPA observed pre-poured medication on the dining room table as both members of staff had left the room to tend to an emergency. A deficiency was cited and licensee agreed to ensure that pre-poured medication is only taken out of central storage when it is ready to be administered or self-administered by the resident to whom it has been prescribed.

As part of the present visit, LPA requested caregiver to demonstrate the medication storage. Central storage is shown to be secured and no medications are observed elsewhere during a tour of the physical plant.

During the complaint investigation visit, it was corroborated that facility had failed to report a COVID-19 outbreak involving both members of staff as well as four (4) residents that occurred on or around 08/20/2022. Facility had been cited accordingly. LPA questioned caregiving staff. Staff states there has not been any further outbreak within the facility.

The plan of corrections for both visits was cleared during today's visit. An exit interview was conducted and a copy of this report along with two plan of corrections clearance letters were printed and left with facility representative.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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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