198602869-12-14-2023-28-AS-CDCN-CYHU7X-20231214142039

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602869
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:20:52 PM

Document Has Been Signed on 12/14/2023 02:20 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	JJVITACARE1, INC		FACILITY NUMBER:	198602869
ADMINISTRATOR:	VITANGCOL, MYRABEL		FACILITY TYPE:	735
ADDRESS:	21321 FOUNTAIN SPRINGS ROAD		TELEPHONE:	(909) 641-7109
CITY:	DIAMOND BAR	STATE: CA	ZIP CODE:	91765
CAPACITY:	6	CENSUS: 5	DATE:	12/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Maria Agustin, Caregiver		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection on 12/14/23. LPA arrived unannounced and met with staff, Maria Agustin. Administrator, Florentino Vitangcol, arrived after to assist with the visit. The facility is licensed to serve 6 adults ages 18 through 59, of which 5 may be non-ambulatory. The home is vendorized by the San Gabriel/Pomona Regional Center. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools to inspect the home. Infection Control: Staff are continuing to clean and disinfect each day. They are using appropriate hand hygiene and wearing gloves when necessary to assist clients. The facility has submitted the Infection Control Plan. Physical Plant & Environment Safety: The facility consists of 4 client bedrooms, 1 Administrator's office, 2 bathrooms, living room, kitchen, family room, and attached garage. There is a carbon monoxide detector located in the living room and smoke detector in each room. Knives, cleaning solutions, and disinfectants are locked and inaccessible to clients. Hot water was measured within the required range of 105 - 120 degrees F. Operational Requirements: The facility is adhering to operational requirements. Staff are providing care and supervision to meet the needs of the clients. Food Service: There are sufficient food supplies of 2-day perishable and (1) week of non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Staffing: There is sufficient staffing at the facility. Administrator Certificate for Florentino Vitangcol expires on 10/22/24. However, the administrator does not have the HIV & TB training as required every 2 years. Staff employed are fingerprint cleared and associated to the facility. There is an awake staff for the overnight shift to provide supervision.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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 12/14/2023 02:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JJVITACARE1, INC	FACILITY NUMBER: 198602869
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(k)

Administrator Qualifications and Duties

(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which the administrator did not receive updated HIV and TB training every 2 years which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2023
	Plan of Correction
1 2 3 4	The administrator shall enroll and receive the HIV and TB training. A copy of the certificate shall be sent to LPA by 12/29/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JJVITACARE1, INC	FACILITY NUMBER: 198602869
	VISIT DATE: 12/14/2023

NARRATIVE

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Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed 3 Staff files. Staff files have current First Aid/CPR certification, Health Screening and Tuberculosis Screening on file. Staff are receiving on-going training.
Client Rights-Information: Client rights are posted at the facility. There are no clients using postural supports.
Client Records-Incident Reports: LPA reviewed files for 5 Clients. The Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Weight Record, Consent Forms, Individual Program Plan/IPP, and Client Rights were observed.
Health Related Services: The medications are centrally stored and locked. LPA reviewed medications for all 5 clients. Medications are being administered as prescribed by the Physician and properly documented.
Incidental Medical Services: No clients have prohibited health conditions or restricted health conditions.
Disaster Preparedness: The facility has the Emergency Disaster Plan which include shut off valves, relocation sites, and procedures in place. The facility conducts fire drills and are documented. However, LPA provided technical advisory to inform administrator that emergency disaster drills shall be conducted at least quarterly for each shift.
Emergency Intervention: Staff have CPI training and does not use manual restraints.

A deficiency is being issued on the LIC809D. An exit interview was held. A copy of this report along with appeal rights are given to the administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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