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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006062
Report Date: 12/19/2022
Date Signed: 12/19/2022 12:05:43 PM


Document Has Been Signed on 12/19/2022 12:05 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 GUEST HOMEFACILITY NUMBER:
306006062
ADMINISTRATOR:DAO, BREVETFACILITY TYPE:
740
ADDRESS:2710 N. BERKELEY STTELEPHONE:
(714) 507-8040
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY:6CENSUS: 6DATE:
12/19/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Teresa Del Pilar- CaregiverTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on 10/31/2022. LPA was greeted and granted entry into the facility by Caregiver Teresa Del Pilar and explained the reason for the visit. Administrator Brevet Dao was unable to be present, but was available by phone.

Deficiency cited under Title 22 Regulation
  • 87303 (b) Maintenance and Operation, licensee replaced all broken screens.
  • 87203 Fire Safety, licensee repaired all non operational smoke alarms, all were tested during POC visit and all are operational.
  • 87465 (h)(2) Incidental Medical and Dental Care, licensee corrected, medications were secured.
  • 87465(h) (6) Incidental Medical and Dental Care licensee updated record keeping for medications for all residents.
  • 87303 (a) Maintenance and Operation, licensee has set up a cleaning schedule and all openings have been sealed.
  • 87307 (d) (6) Personal Accommodations and Services, licensee showed proof that all walkways were cleared.


Licensee has complied with the POC.





Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2022
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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