<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603358
Report Date: 12/20/2021
Date Signed: 12/20/2021 03:41:59 PM

Document Has Been Signed on 12/20/2021 03:41 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SUPERCARE GUEST HOMEFACILITY NUMBER:
198603358
ADMINISTRATOR:JABONERO, JANICE RACHELLEFACILITY TYPE:
740
ADDRESS:13449 BIOLA AVETELEPHONE:
(714) 244-5885
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY: 6CENSUS: 4DATE:
12/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Janice Jabonero TIME COMPLETED:
12:30 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) Jose Villalobos made and unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Licensee Ruby Lyn Cruz and Administrator Janice Jabonero. The purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed (4) resident records, (2) staff files, and (4) resident medications. Currently the facility has (4) residents which (3) are ambulatory and (1) is non-ambulatory. Facility is a one story family home with four (4) bedrooms, two (2) bathrooms, living room, kitchen, central air and heating, dining area, gated fire place located in the living room, laundry room, a shaded area located in the backyard. an attached garage inaccessible to residents. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Bedrooms #1-#4 required furnishing. Bathroom have a working toilet, wash basin, and shower. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies were observed. Fire alarms are interconnected and operational. Required postings observed. Water temperature within required tittle 22 regulations.

Infection control domain completed and there were no deficiencies. An exit interview was conducted.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2021
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 1