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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850151
Report Date: 07/18/2022
Date Signed: 07/18/2022 12:29:37 PM


Document Has Been Signed on 07/18/2022 12:29 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:JIREH SENIOR HOMEFACILITY NUMBER:
425850151
ADMINISTRATOR:NAVARRO, JESUSFACILITY TYPE:
740
ADDRESS:2102 CALLE MIRASOLTELEPHONE:
(805) 863-1926
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: 3DATE:
07/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Patricia Montano Hernandez, LicenseeTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Olson conducted an on-site 1 year infection control annual visit to the facility above on 07/18/2022 at 11:10 AM. LPA met with Patricia Montano Hernandez, Licensee and Staff Rayna Morales and explained the purpose of the visit.

LPA took a physical plant tour of the inside and outside of the facility with Staff. The facility has an entry point at the front door where everyone entering completes sign-in, symptoms screening and temperature check. All documentation is kept on file.

The staff screen residents for symptoms and temperature once a day and keep documentation in a binder. Increased monitoring will be conducted if any change of condition are noted or if any resident is showing any signs, symptoms or a temperature. Signs are posted on the front door, entry area regarding Covid-19. Staff makes sure residents have a mask when leaving the facility on outings into the community. Staff wear masks in the facility and while on outings with residents.

Facility has areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. Staff, Residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility.

The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Licensee is in charge of infection control and provides training and education to staff, residents and visitors.



Continued 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JIREH SENIOR HOME
FACILITY NUMBER: 425850151
VISIT DATE: 07/18/2022
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If any suspected or confirmed cases of Covid-19 are found in the facility a staff will use PPE supplies that will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Facility has plans for delivering medications and meals to any quarantined or isolated resident room. The facility has proper cleaning and disinfectant policies. Licensee has a plan in place for when and whom to notify in an outbreak or other emergencies. Licensee will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap, paper towels and hand washing signs. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by any of these agencies.

No deficiencies observed during the visit, all infection control protocols are implemented and being followed.

Exit interview conducted and copy of report emailed to Administrator/Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2