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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604214
Report Date: 07/09/2024
Date Signed: 07/09/2024 05:33:49 PM

Document Has Been Signed on 07/09/2024 05:33 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:JERIJAN HAPPY HOMEFACILITY NUMBER:
374604214
ADMINISTRATOR/
DIRECTOR:		ANTONIO, JERIJANFACILITY TYPE:
735
ADDRESS:580 JUNIPER STREETTELEPHONE:
(619) 422-2036
CITY:CHULA VISTASTATE: CAZIP CODE:
91911
CAPACITY: 4CENSUS: 4DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Caregiver Lilia Yanit and Administrator Jerijan AntonioTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Lilia Yanit. LPA then met with Administrator Jerijan Antonio, who arrived shortly after.

According to the facility’s license, the facility has a maximum capacity for four (4) clients, of whom all may be ambulatory and up to two (2) clients may be non-ambulatory, but none may be bedridden. Per LPA observation and review of each client’s latest LIC602 Physician’s Report: During today’s visit, there were a total of four (4) clients in care, of whom all were ambulatory. This facility’s license does not include endorsements for secured perimeter or delayed egress doors, and none of these were present during the visit.

During today’s visit, LPA interviewed multiple staff and clients. LPA also reviewed all staff and client records/files. LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in general good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens, hygiene supplies, and Personal Protective Equipment were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was complaint at 70 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen Sink was 110.3 F, Bathroom #1 Sink was 110.1 F, and Bathroom #2 Sink was 107.4 F. Appliances to preserve perishable food were also compliant in temperature: Kitchen Refrigerator was 39 F and Kitchen Freezer was 0 F. Garage Refrigerator was 39 F and Garage Freezer was 0 F. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. [CONTINUED ON LIC 809]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: JERIJAN HAPPY HOME
FACILITY NUMBER: 374604214
VISIT DATE: 07/09/2024
NARRATIVE
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[CONTINUED FROM LIC 809] There were no sharp objects, toxic chemicals/poisons, active fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detector, night lights, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher was serviced within the last twelve (12) months. A complete first aid kit was present and readily accessible. Required licensing postings were observed in visible areas of the facility. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond.

LPA observed, and manager interview confirmed, that of the five (5) smoke alarms that were present at the facility during the initial fire clearance inspection, today one (1) was non-operating due to dead batteries, and one (1) was missing altogether. Records reviewed, corroborated by manager interview, showed: While Licensee’s staff performed several disaster drills over the last three (3) years, these drills occurred only on the afternoon (PM) shift, leaving out the morning (AM) and overnight (NOC) shifts. The frequency of drills was also less than the quarterly requirement.

Records reviewed, corroborated by staff interviews, also showed: Client #1 (C1) and Client #2 (C2) both required staff assistance with taking their prescribed inhaler medication. [See LIC811 Confidential Names List for a description of C1 and C2.] C1 had been using their inhaler since 2017, and C2 had been using their inhaler since 2020. However, Licensee did not ensure that its direct care staff were initially trained by a licensed professional on how to assist these clients with inhaler devices, as was required. Licensee also did not ensure that a licensed professional reviewed the assisting staff’s performance on the clients’ inhalers at least annually, as was required.

Three (3) deficiencies were cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued Technical Assistance (TA) regarding staff auditory alert devices on exit doors (refer to the attached LIC 9102-TA page).

An exit interview was conducted with Antonio, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TA page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/09/2024 05:33 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/09/2024 at 04:34 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and manager interview, Licensee did not maintain full ongoing compliance with its prior-approved fire clearance, which posed a potential safety risk to 4 of 4 clients (C1 through C4) in care.
POC Due Date: 07/09/2024
Plan of Correction
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Of the five (5) smoke alarms that were present at the facility during the initial fire clearance inspection: One (1) smoke alarm was non-operating due to dead batteries. One (1) smoke alarm was missing altogether. During today's visit, Licensee replaced the batteries on the first alarm, fixing it. Licensee then purchased another smoke alarm to replace the missing one. LPA saw proof of payment showing the online purchase was placed. Licensee agreed to install it as soon as it arrives. These actions resolve the deficinecy.
Type B
Section Cited
CCR
80075(b)(1)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must receive training from a licensed professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interviews, 2 of 4 clients (C1 and C2) in care required staff assistance with inhalers. However, Licensee did not ensure that 4 of 4 assisting staff received training on inhalers from a licensed professional. This posed a potential health risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Licensee agreed to coordinate with a currently-licensed nurse to lead training for all existing facility staff (who assist clients with medication) on how to correctly and safely use inhaler devices to deliver medication, to include the nuances of C1 and C2's specific inhalers, if any. Licensee agreed to E-mail the training sign in sheet to LPA, by the POC due date. The training sign in sheet will indicate the trainer's full name, employing agency, and nursing license number.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/09/2024 05:33 PM - It Cannot Be Edited


Created By: Dang Nguyen On 07/09/2024 at 04:34 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(1)(A)2
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (1) In adult CCFs, facility staff who receive training may assist clients with metered-dose inhalers, and dry powder inhalers if the following requirements are met: (A) In ARFs, facility staff must receive training from a licensed professional. 2. The licensee ensures that the licensed professional reviews staff performance as the licensed professional deems necessary, but at least once a year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and staff interviews, 2 of 4 clients (C1 and C2) in care required staff assistance with inhalers. However, Licensee did not ensure that 4 of 4 staff had their performance on inhalers reviewed at least once per year by a licensed professional. This posed a potential health risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Licensee agreed to coordinate with a currently-licensed nurse to lead training for existing facility staff on inhaler use, and to E-mail the training sign in sheet to LPA, by the POC due date. Going forward, Licensee agreed to have the nurse review its staff performance on inhalers as often as needed, but at least once per year, and to document the nurse's evaluations in writing as part of the facility's training records.
Type B
Section Cited
HSC
1565(c)
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 individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview: Licensee did not conduct an emergency/disaster drill at least quarterly for each shift. This posed a potential safety risk for 4 of 4 clients (C1 through and C4) in care.
POC Due Date: 08/09/2024
Plan of Correction
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Licensee agreed to perform an emergency/disaster drill on the morning AM shift (6:00 AM to 2:00 PM) and the overnight NOC shift (i.e., 10:00 PM to 6:00 AM), and to document the results of these drills in writing. Licensee agreed to E-mail proof of drills completion, by the POC due date. Going forward, Licensee agreed to perform an emergency/disaster drill at least quarterly for each shift.
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:Lizzette Tellez
LICENSING EVALUATOR NAME:Dang Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
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