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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004786
Report Date: 02/15/2022
Date Signed: 02/15/2022 04:01:15 PM

Document Has Been Signed on 02/15/2022 04:01 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:J.O.Y. HOMECAREFACILITY NUMBER:
306004786
ADMINISTRATOR:MARIFEL ANTONETTE V. IVERSFACILITY TYPE:
740
ADDRESS:20181 CROWN REEF LANETELEPHONE:
(714) 369-2780
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 4DATE:
02/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Marifel Antonette V. IversTIME COMPLETED:
04:15 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Administrator (AD) Marifel Antonette V. Ivers and discussed the purpose of the inspection. During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage, and kitchen and observed the following:
LPA and AD observed there were 2 staff present. LPA observed 4 residents were present. LPA confirmed all residents were doing well. LPA inspected common areas, resident rooms, garage, and kitchen, and observed they were clean and organized. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.
During the inspection, LPA and AD observed the following: a resident residing in the south west room, designated on the floor map as a den/staff room, that commonly acts as the hallway/passageway to the backyard. AD stated that the resident had previously resided in one of the facility’s resident rooms, but had requested to live in the den/staff room recently. During the inspection, AD began the process of moving the resident back to their proper room, including by moving the resident’s clothes and personal items and LPA confirmed. Proof of the completion of the relocation will be sent to LPA by plan of correction due date.
LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and dementia. LPA provided technical assistance regarding N95 fit testing and storage. LPA requested and reviewed resident roster, staff roster, staff files, resident files, emergency plan, and COVID-19 mitigation plan.
Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2022
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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Document Has Been Signed on 02/15/2022 04:01 PM - It Cannot Be Edited


Created By: Sean Haddad On 02/15/2022 at 03:35 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: J.O.Y. HOMECARE
FACILITY NUMBER: 306004786

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)


Type B: CCR 87307(a)(2)(B) – 87307 Personal Accommodations and Services (a) ... The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. ... This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not prevent 1 resident out of 4 from sleeping in a room not designated as a resident room on the floor map, but instead designated as a den/staff room and commonly used as a hallway to the backyard, which poses a potential safety and personal rights risk to persons in care.
POC Due Date: 02/22/2022
Plan of Correction
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POC: Licensee immediately began the process of moving the resident back to their proper room, including by moving the resident’s clothes and personal items and LPA confirmed. Licensee states they will submit proof of completion of the relocation to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Marina Stanic
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2022


LIC809 (FAS) - (06/04)
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