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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006003
Report Date: 08/28/2024
Date Signed: 08/28/2024 10:58:51 AM

Document Has Been Signed on 08/28/2024 10:58 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JADE FAMILY HOMESFACILITY NUMBER:
306006003
ADMINISTRATOR/
DIRECTOR:		MAURICIO, ADORACIONFACILITY TYPE:
735
ADDRESS:2528 W. OAK AVETELEPHONE:
(657) 500-8048
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 6CENSUS: 4DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Adoracion MauricioTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On August 28, 2024 at 8:00am, Licensing Program Analyst (LPA) Edward Kim conducted an unannounced required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Kim was greeted and granted entry by Administrator (AD) Adoracion Mauricio and LPA Kim explained the purpose of the visit.

The facility is licensed to operate for six (6) nonambulatory clients. The facility is a single story structure located in a residential neighborhood. It consists of the following: five (5) client bedrooms, one recreation room, three (3) bathrooms, living area, dining area, kitchen, detached garage, and outside covered patio area.

LPA Kim toured inside and outside of the physical plant with AD Mauricio. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. The Client’s rooms were inspected: Client Room 1, Client Room 2, Client Room 3, Client Room 4, and Client Room 5. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at between 105.8 degrees F and 106.5 degrees F. A comfortable temperature of 77 degrees F was maintained in the facility.

LPA Kim observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to clients. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. Emergency food, emergency water, and emergency supplies were stored in the recreation room. The facility has (1) fire extinguisher that was charged, mounted in the garage, and serviced on August 12, 2024.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JADE FAMILY HOMES
FACILITY NUMBER: 306006003
VISIT DATE: 08/28/2024
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During the visit, LPA Kim observed the facility's infection control practices, plan of operation, and screening protocols for visitors, staff, and clients. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility conducts Fire/Safety Drills monthly and last conducted on August 15, 2024. The smoke detectors and carbon monoxide detectors were operable. A working telephone (657-500-8048) remains available. First Aid kit had all the necessary elements.

LPA Kim conducted an audit of client files (C1-C4), staff files (S1-S7), P&I funds, and medication and medication administration review that were all in order and complete. LPA Kim conducted three (3) staff interviews and one (1) client interview.

No deficiencies were cited during this inspection visit.

An exit interview was conducted, and a copy of this report was provided to Administrator Adoracion Mauricio

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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