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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005418
Report Date: 11/22/2021
Date Signed: 11/22/2021 02:51:36 PM

Document Has Been Signed on 11/22/2021 02:51 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:JC HOME FOR SENIORS - LOVEFACILITY NUMBER:
306005418
ADMINISTRATOR:PARUNGAO, MARIA- EMETERIOFACILITY TYPE:
740
ADDRESS:19851 ISTHMUS LANETELEPHONE:
(714) 968-9795
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 5CENSUS: 5DATE:
11/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:16 PM
MET WITH:Administrator, Maria- Emeterio Parungao

TIME COMPLETED:
03:00 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 and granted entry into the facility and explained the reason for the visit. LPA Tirre toured facility with Caregiver.

During the visit, Administrator Maria Emeterio Parungao arrived. Facility is a 5 bedroom (4 resident rooms, 1 staff) and 2 bathroom single story home. There are 5 Residents in care. LPA observed proper covid signage in entry way of facility. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring 2022. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper and paper towels. Restrooms had proper hand washing signs. LPA observed a visitation area with ample seating. Residents were observed relaxing in the Living room watching TV. Facility has audible alarm system and smoke detectors. Facility has 1 fire extinguisher fully charged. Facility has ample emergency food and water supply. Facility has required Emergency Disaster Plan posted inside facility. Facility has a secured location for resident medication and files. LPA observed residents medications and facility has 30 days supply of medications for Residents. Residents emergency contact information and Physicians reports are current.


No deficiencies noted during todays visit. An exit interview was conducted with Administrator Maria Emeterio-Parungao and a copy of this report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2021
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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