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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005230
Report Date: 07/20/2021
Date Signed: 07/20/2021 12:40:08 PM

Document Has Been Signed on 07/20/2021 12:40 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:JAN'S HOUSE LLCFACILITY NUMBER:
306005230
ADMINISTRATOR:JOINER, KERRYFACILITY TYPE:
740
ADDRESS:16970 MOUNT EDEN STTELEPHONE:
(714) 486-2959
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 6CENSUS: 6DATE:
07/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Administrator Amy DeBoomTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted, granted entry into the facility by Staff and explained the reason for the visit.

During the visit LPA toured the facility with Administrator Amy DeBoom. Facility is a 6 bedroom,( 5 resident bedrooms 1 staff bedroom) and 4 bathroom single story home. There are 6 Residents in care. LPA observed proper covid signage at front entrance of facility as well as sign in, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring June 28, 2022. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper, paper towels, disinfection wipes and hand sanitizer. Residents were observed relaxing in the Living room and eating lunch in kitchen. Facility has working smoke detectors and audible alarms. Facility has 1 fire extinguisher which is fully charged. Facility has supply of PPE. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for residents. LPA reviewed Residents files during visit. Residents emergency contact information and Physicians reports are current. Facility has a designated visitation area.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator Amy DeBoom and a copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2021
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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