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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800195
Report Date: 07/13/2023
Date Signed: 07/13/2023 01:21:02 PM

Document Has Been Signed on 07/13/2023 01:21 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:JDJ BEHAVIORAL INCORPORATEDFACILITY NUMBER:
361800195
ADMINISTRATOR:ELIZABETH GONZALEZFACILITY TYPE:
735
ADDRESS:2385 PEACOCK AVENUETELEPHONE:
(909) 907-5867
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 4CENSUS: 4DATE:
07/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Diana Navarrete - DSPTIME COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for an annual inspection. LPA met with DSP (direct support provider) Diana Navarrete. The facility is vendored by the Inland Regional Center. LPA observed one client present during today's visit.

LPA and DSP toured the facility inside and LPA walked the outside. The facility has no bodies of water. The facility has charged fire extinguishers, operating smoke alarm and carbon monoxide detectors. Cleaning supplies and sharps were kept in a safe and locked place. Medications were kept in a locked closet. Sharps were secured and inaccessible in a cabinet. The facility had a complete first aid kit and manual. LPA observed two (2) days supply of perishable food items and seven (7) days supply of nonperishable food items. The facility menu and monthly activities schedules were available for review. The client bedrooms had the required furniture and sufficient lighting. The facility had a supply of additional linen and extra hygiene items. LPA measured the hot water temperature, which was recorded between 108-118 degrees F. LPA also observed emergency supplies.

LPA reviewed client files. Client files had the required documentation including an admissions agreement and Individual Program Plan (IPP). LPA reviewed client medications and medication administration record. LPA was not able to view staff files.

BEcause LPA was not able to review staff records, this poses a potential health and safety risk to clients in care. Refer to LIC809-D for deficiency cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed and provided to facility staff.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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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Document Has Been Signed on 07/13/2023 01:21 PM - It Cannot Be Edited


Created By: Anna Bueno On 07/13/2023 at 12:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: JDJ BEHAVIORAL INCORPORATED
FACILITY NUMBER: 361800195

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on facility observation and staff interview, the Licensee did not comply with the section cited above due no staff files are available for review during LPA's visit. Per Administrator, staff files are locked and Administrator is the only one who has access to the secured staff files. This poses/posed a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 07/21/2023
Plan of Correction
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Licensee shall, at all times, provide a means to allow access for staff file review as requested by the authorized agency. Access means, but is not limited to, keeping staff files unsecured or leaving a key to access files with staff on duty.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nedra Brown
LICENSING EVALUATOR NAME:Anna Bueno
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023


LIC809 (FAS) - (06/04)
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