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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006012
Report Date: 08/30/2022
Date Signed: 08/30/2022 03:38:21 PM


Document Has Been Signed on 08/30/2022 03:38 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:JENN'S RESIDENTIAL CARE FACILITY FOR THE ELDERLYFACILITY NUMBER:
306006012
ADMINISTRATOR:LUCAS, JENNIFERFACILITY TYPE:
740
ADDRESS:2960 CHAMPION WAY #2701TELEPHONE:
(714) 464-9260
CITY:TUSTINSTATE: CAZIP CODE:
92782
CAPACITY:2CENSUS: 0DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jennifer LucasTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Licensee/ Administrator Jennifer Lucas and explained the reason for the visit. There are no residents in care during today's visit.

At 2:09 PM, LPA toured the facility with Administrator Lucas. Facility has no residents in care during today's visit. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA observed the first aid kit has all required items. LPA observed an ample supply of emergency food and water. Smoke detectors tested operational during today's visit. LPA observed a shaded patio. LPA observed the locked medication storage area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA advised Licensee to implement the following prior to accepting a resident:
  • Please post covid signage outside the facility.
  • Please implement a screening/ health questionnaire station for visitors entering the facility.
  • Please post hand washing signs in the restrooms.
  • Post the "Let Us No" poster in regulation size, 20" X 26."
Licensee to notify LPA upon admitting residents to the facility.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
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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