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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006003
Report Date: 08/12/2021
Date Signed: 08/16/2021 07:09:49 AM

Document Has Been Signed on 08/16/2021 07:09 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JADE FAMILY HOMESFACILITY NUMBER:
306006003
ADMINISTRATOR:MAURICIO, ADORACIONFACILITY TYPE:
735
ADDRESS:2528 W. OAK AVETELEPHONE:
(714) 767-2620
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 0DATE:
08/12/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Adoracion MauricioTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Lydia Martinez conducted a visit to the facility to conduct an announced Pre-Licensing evaluation. Upon arrival, LPA met with Applicant Adoracion Mauricio. An initial application to operate an Adult Residential Facility (ARF) was submitted to the Central Applications Unit (CAU) on 04/12/2021 for a capacity of 6 non-ambulatory clients. The Fullerton Fire Department conducted a Fire Safety Inspection on 06/09/2021 and granted a Fire Clearance. A tour of the physical plant was conducted inside and out at approximately 9:40 am with Mrs. Mauricio and the following was observed:
Structure:
Facility is a one story house with 5 bedrooms and 3 bathrooms. Bedroom #1 through #4 are designated as client bedrooms and are authorized for non-ambulatory client use. There is a living room, dining area, office and kitchen. Staff bedroom is #5.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Clients:
The client bedrooms( #1-#4) accommodate clients' furnishings and meet Title 22 regulation at this time.
Bathrooms:
The 3 bathrooms have a working toilet, wash basin, and shower. Grab bars and non-slip mats were present.
Linens and Hygiene Supplies
Adequate supply of linens and hygiene items were observed
Ombudsman Poster, Personal Rights and See Something Say Something Poster
Ombudsman poster will be obtained once licensed, Personal Rights and See Something Say Something were posted.
Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables will be stored in the kitchen and pantry and will include fruits and vegetables.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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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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: JADE FAMILY HOMES
FACILITY NUMBER: 306006003
VISIT DATE: 08/12/2021
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Smoke and Carbon Monoxide Detectors:
Smoke detectors and carbon monoxide systems were observed working at the time of this visit
Fire Extinguishers:
The fire extinguisher was mounted and fully charged at the time of this visit
Fire Clearance:
Approved on 06/09/2021
Appliances:
Refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer were clean and noted to be operational.
Toxins:
Will be locked and inaccessible to clients
Water Temperature:
Tested and recorded at 119 degrees F.
Medications, First Aid Kit & Manual:
First Aid kit with guide is stored in the office. Medication will be stored and locked in the facility dining area in a locked cabinet.
Client and Staff Files:
Records will be kept locked in the office for privacy

A Component III Orientation was conducted during this Pre-Licensing visit. Applicant demonstrated a clear, concise and comprehensive knowledge of medication protocols, documentation and preventative protocols.

The Pre-Licensing inspection has been completed. It appears this facility meets the requirements for licensure. The license will be granted upon completion of a final review and approval from the Application Specialist.



An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC809 (FAS) - (06/04)
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