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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602759
Report Date: 09/18/2023
Date Signed: 09/18/2023 04:44:13 PM

Document Has Been Signed on 09/18/2023 04:44 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
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HOUSE OF JFACILITY NUMBER:
374602759
ADMINISTRATOR:DIZON, JOSIEFACILITY TYPE:
735
ADDRESS:1170 DALLAS ROADTELEPHONE:
(760) 645-0476
CITY:FALLBROOKSTATE: CAZIP CODE:
92028
CAPACITY: 6CENSUS: 4DATE:
09/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Josie Dizon, AdministratorTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct the required annual licensing inspection. LPA stated purpose of today’s visit was to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. The facility serves Developmentally Delayed adults. LPA was granted entry into the facility and met with Co-Administrators Jake Dizon and John Nausler. There were four (4) clients and two (2) staff present during today's visit. Administrator Josie Dizon arrived shortly. A tour of the facility was conducted inside and out.

The facility is a five (5) bedroom, three (3) bathroom home. Three (3) bedrooms are shared, two clients to a room and two bedrooms are reserved for live-in staff. All bedrooms have the required furnishings and furniture is in good repair. Each client has clean and sufficient bed linens and towels/washcloths. Carbon monoxide and smoke alarms are operational. Drills are conducted quarterly. The last fire drill was conducted on 06/24/23. There are no bodies of water on the facility. Exterior and interior passageways are obstruction free. Disinfectants, cleaning solutions, poisons were inaccessible to clients during the time of the visit. Lighting is present in all rooms. The facility temperature was 76 degrees at the time of the visit. Hot water temperature measured at 115.7 degrees Fahrenheit for the bathroom used by the clients. The client bathroom was observed to be sanitary and in operating condition. LPA observed sufficient supply of linens and hygiene products. Per Administrator Dizon, there are no weapons and/or ammunition housed in the facility.

The facility was stocked with a 2-day supply of perishable and a 7-day supply of nonperishable food items. The food was observed properly stored. Medications are stored in a locked cabinet inaccessible to clients.


SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HOUSE OF J
FACILITY NUMBER: 374602759
VISIT DATE: 09/18/2023
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Client records were reviewed and observed to contain the necessary completed documents. LPA reviewed P&I logs, records are balanced. P&I funds are kept separately from facility funds. Staff records were reviewed and also observed to contain the necessary documentation. Per staff records reviewed, individuals subject to a criminal record review obtained clearance and/or an exemption; staff responsible for direct care and supervision have current first aid training. Administrator Josie Dizon certificate expires on 03/26/2024.

Emergency exiting plans, telephone numbers and Ombudsman information and other required signage are posted throughout the facility.

LPA reviewed medication and medication log. Residents' medications are being dispensed according to physician's orders.

No deficiencies were cited per Title 22, Division 6 of the California Code of Regulations at this time.

An exit interview was conducted and a copy of this report was provided to Administrator,.
Josie Dizon.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC809 (FAS) - (06/04)
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