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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006024
Report Date: 11/05/2024
Date Signed: 11/05/2024 03:14:14 PM

Document Has Been Signed on 11/05/2024 03:14 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JEM4 HOME CAREFACILITY NUMBER:
306006024
ADMINISTRATOR/
DIRECTOR:		SANTOS, LOPEFACILITY TYPE:
735
ADDRESS:3218 W. SUNVIEW DRIVETELEPHONE:
(657) 256-1565
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 4CENSUS: 4DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Melba Santos, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Staff #1. During today’s visit, LPA met with Melba Santos, Administrator.

The facility is a four bedroom, two bathroom level 4c single-story building with an approved fire clearance of three ambulatory and one non-ambulatory. The facility currently has a census of four clients in care.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperatures in two of two client bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 109.5 and 114.2 degrees Fahrenheit and all smoke and carbon monoxide detectors were operational. The fire extinguisher is charged and was serviced on August 30, 2024. The facility’s last fire drill was conducted on August 20, 2024.

LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review medications are being given as prescribed. The First Aid kit had all the required elements and facility has a First Aid Manual book.

LPA toured the exterior and observed a shaded seating area, one exit gate with a latch and a pool area that is secured with fencing. The pool gate latch was placed within six inches of the top of the gate and is locked. Client bedrooms had the required furnishings and linens and all sharps and chemicals were stored and locked in cabinets.

(Continued on LIC 809-C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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: JEM4 HOME CARE
FACILITY NUMBER: 306006024
VISIT DATE: 11/05/2024
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(Continued from LIC 809)

LPA reviewed three of three staff training and fingerprint records and conducted a complete review of client records. Administrator created an Admissions Agreement for all clients to comply with Title 22 and will obtain required signatures to place in charts. Client P&I records were reviewed and were accurate. LPA interviewed an alert client regarding the quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a pending renewal administrator certificate which will expire on June 30, 2026.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiencies cited on this date. An exit interview was conducted with Melba Santos, Administrator and a copy of the report, and files reviewed (LIC 858 & LIC 859) were given at the time of the visit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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