<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006003
Report Date: 08/24/2022
Date Signed: 08/24/2022 03:19:55 PM

Document Has Been Signed on 08/24/2022 03:19 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:JADE FAMILY HOMESFACILITY NUMBER:
306006003
ADMINISTRATOR:MAURICIO, ADORACIONFACILITY TYPE:
735
ADDRESS:2528 W. OAK AVETELEPHONE:
(657) 500-8048
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 2DATE:
08/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Adoracion MauricioTIME COMPLETED:
03:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA met with Administrator (AD) Adoracion Mauricio. LPA discussed the purpose of the inspection. During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a single-story house with six bedrooms and three bathrooms. Clients were observed resting in their respective rooms. Upon entry LPA noted a hand sanitizer station. Hallways and walkways were free of obstruction. A 2-day supply of perishable and a 7-day supply of non-perishable food was observed during today’s visit. All fire extinguishers observed were found to be within regulation. No bodies of water were observed during today's visit.

LPA Gutierrez reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2022
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 1