360908446-12-2-2024-56-AS-JPRO-DBKTF8-20241202134108

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 360908446
Report Date: 12/02/2024
Date Signed: 12/02/2024 04:25:22 PM

Document Has Been Signed on 12/02/2024 04:25 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	JACE GUEST HOME		FACILITY NUMBER:	360908446
ADMINISTRATOR/ DIRECTOR:	YAN, CECILE		FACILITY TYPE:	740
ADDRESS:	11393 YORBA STREET		TELEPHONE:	(909) 628-8640
CITY:	CHINO	STATE: CA	ZIP CODE:	91710
CAPACITY: 15	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Cecile Yan, licensee and Maria Maraget Kirit, administrator		TIME VISIT/ INSPECTION COMPLETED:	01:55 PM

NARRATIVE

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Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Licensee Cecile Yan and was granted entry to the facility. At the time of the visit there was three (3) staff present, six (6) residents present at time of inspection. The facility is an nine (9) bedroom, five (5), bathroom home, with a kitchen/dining area, living room, family room with an attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (15) current census (6). LPA was accompanied by Facility Licensee, to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 107.9 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside medication closet inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Today's inspection reveals that emergency disaster drill have not been conducted for at least one year.

Karen Clemons	TELEPHONE: (951) 248-0349
Javier Prieto	TELEPHONE: 951-217-3135
	DATE: 12/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: JACE GUEST HOME	FACILITY NUMBER: 360908446
	VISIT DATE: 12/02/2024

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Record Review: LPA reviewed six (6) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Resident records for resident #1 (R1) and R2 reveals the Physician's Report was not done annually.

Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) and LIC 809D, along with an appeals rights, was discussed and provided to Facility Licensee Cecile Yan.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/02/2024 04:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: JACE GUEST HOME	FACILITY NUMBER: 360908446
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview , the licensee did not comply with the section cited above in 1 out of 1 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2024
	Plan of Correction
1 2 3 4	Licensee is to submit a written declaration that emergency disaster drill was conduct. sent to licensee via email.

Section Cited

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 6 persons which poses/posed a potential health, safety or personal rights risk to persons in care. Resident #1 and resident #2 did not have an undated yearly Physician's Report.
	POC Due Date: 12/16/2024
	Plan of Correction
1 2 3 4	Licensee to send LPA an updated Physician Report by POC date via email.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Karen Clemons	TELEPHONE: (951) 248-0349
Javier Prieto	TELEPHONE: 951-217-3135
	DATE: 12/02/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024

LIC809 (FAS) - (06/04)

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