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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006003
Report Date: 09/28/2023
Date Signed: 09/28/2023 10:09:09 AM

Document Has Been Signed on 09/28/2023 10:09 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:
(657) 500-8048
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 4DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Adoracion MauricioTIME COMPLETED:
10:25 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Administrator (AD) Adoracion Mauricio and explained the purpose of the inspection. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with five client bedrooms, three bathrooms, laundry room and staff office. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The back yard has a shaded sitting area. LPA observed one staff and one client present, as all other clients were away at day program. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 110.3-110.4 F degrees. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted at the entrance of the facility. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged. Disaster drill log indicated last drill was conducted on 8/11/23. Stove burners, microwave, washer, and dryer were all inspected and tested operational. Sharps were observed locked in the staff office. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was also observed to be locked. LPA reviewed four client files and four staff files. Clients were not present to be interviewed. LPA interviewed one staff present.

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: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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