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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005501
Report Date: 04/11/2024
Date Signed: 04/11/2024 04:15:49 PM

Document Has Been Signed on 04/11/2024 04:15 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:JEWEL HOMECARE 1FACILITY NUMBER:
306005501
ADMINISTRATOR/
DIRECTOR:		PAO, WESLEYFACILITY TYPE:
740
ADDRESS:5111 HAMER LNTELEPHONE:
(424) 270-4452
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: DATE:
04/11/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:20 PM
MET WITH:Macario PardilloTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit for the purpose of conducting a Plan of Correction (POC) inspection. LPA was greeted and granted entry by Staff Macario Paradillo. Administrator (AD) Wesley Pao was contacted by phone at approximately 3:40 p.m. and LPA explained the purpose of the visit.

LPA is following up on deficiencies cited on 3/19/23, during annual/required inspection. Deficiency 87465(a)(6) was cited due to resident records of centrally stored medication not being maintained. During today’s visit, LPA Gutierrez was unable to conduct a record review of centrally stored medication as a record is still not currently being maintained. Deficiency 87465(h)(2) was cited due to medication being accessible to residents on the kitchen counter, in an unlocked kitchen drawer and in an unlocked kitchen cabinet. During today’s visit, LPA verified all, and any medication is locked in the medication cabinet.

One of two deficiencies previously cited will be cleared.

Based on today’s observations one deficiency is being re-cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
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 04/11/2024 04:15 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 04/11/2024 at 04:04 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: JEWEL HOMECARE 1
FACILITY NUMBER: 306005501

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2024
Section Cited
CCR
87465(h)(2)

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When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
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AD stated they will maintain a record of centrally stored medication and keep it up to date. AD stated staff training will conducted to ensure records are accurately maintained. LPA will made an additional visit to ensure POC has been met.
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Based on observation and staff interview, the licensee did not comply with the section cited above as resident records for centrally stored medication is not being maintained, which poses an immediate health, safety and personal rights risk to persons in care.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024


LIC809 (FAS) - (06/04)
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