374604214-7-28-2023-08-AS-ARAZ-CU6T8S-20230728143050

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604214
Report Date: 07/28/2023
Date Signed: 07/28/2023 02:31:01 PM

Document Has Been Signed on 07/28/2023 02:31 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	JERIJAN HAPPY HOME		FACILITY NUMBER:	374604214
ADMINISTRATOR:	ANTONIO, JERIJAN		FACILITY TYPE:	735
ADDRESS:	580 JUNIPER STREET		TELEPHONE:	(619) 422-2036
CITY:	CHULA VISTA	STATE: CA	ZIP CODE:	91911
CAPACITY: 4		CENSUS: 4	DATE:	07/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator Jerijan Antonio		TIME COMPLETED:	03:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with administrator Jerijan Antonio. According to the facility’s license, the facility has a maximum capacity of four (4) clients, of which two (2) may be non-ambulatory. There was a total of four (4) client in care.

LPA, accompanied by administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 116 F, bathroom #1 sink was 116 F and bathroom #2 was 116 F .

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: JERIJAN HAPPY HOME	FACILITY NUMBER: 374604214
	VISIT DATE: 07/28/2023

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[CONTINUED FROM LIC 809]

No pools or bodies of water were present. Per administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA reviewed multiple staff and client records/files. Two (2) out of three (3) staff (S1 & S2) were missing LIC503 health screening report and TB tests. The rest of the files which LPA reviewed contained required documents. Confidential records were stored in locked area.

Deficiencies were cited during today's annual inspection and plan of correction was created with administrator.

An exit interview was conducted with Antonio to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/28/2023 02:31 PM - It Cannot Be Edited

Created By: Alyssa Ramirez On 07/28/2023 at 02:17 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: JERIJAN HAPPY HOME	FACILITY NUMBER: 374604214
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(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: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in [count] out of two (2) out of three (3) staff (S1 & S2) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2023
	Plan of Correction
1 2 3 4	Licensee will submit completed LIC 503 to LPA Ramirez by email by POC due date.

Type B

Section Cited

CCR

80066(a)(11)

Personnel Records

(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: (11) Tuberculosis test documents as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in [count] out of two (2) out of three (3) staff (S1 & S2) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2023
	Plan of Correction
1 2 3 4	Licensee will submit TB test results to LPA Ramirez by email by POC due date.

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:

Simon Jacob

LICENSING EVALUATOR NAME:

Alyssa Ramirez

LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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