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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005501
Report Date: 04/30/2024
Date Signed: 04/30/2024 03:54:40 PM

Document Has Been Signed on 04/30/2024 03:54 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: 5DATE:
04/30/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Wesley PaoTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced Plan of Correction (POC) inspection. LPA was greeted and granted entry by Staff Macario Paradillo. Administrator (AD) Wesley Pao was contacted by phone and arrived at approximately 2:00 p.m. and LPA explained the purpose of the inspection.

Deficiencies 87465(a)(6), 87465(h)(5), 87465(h)(2), 87463(a), 87463(c),1569.695(c), 87303(e)(3) were previously cited on March 19, 2024, during facility's annual/required inspection. During POC visit on April 11, 2024, LPA verified POC for deficiency 87465(a)(6) was met. During today’s visit, LPA verified the other six POCs for citations listed were met as well, and deficiencies previously cited will be cleared.

Deficiencies 1569.625(b)(2),1569.696(a), 1569.69(a)(2) will be re-cited as POCs have not been met.



Based on today’s observations, three deficiencies are 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: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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 04/30/2024 03:54 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 04/30/2024 at 03:14 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: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2024
Section Cited
HSC
1569.625(b)(2)

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...training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training... and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care...
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AD stated staff training will continue to be conducted to meet regulation requirement. AD will provide LPA with proof of staff training conducted via email by POC date.
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This requirement is not met as evidenced by:
Based on record review, the licensee did not comply with the section cited above as staff have not completed required training, which poses a potential health, safety and personal rights risk to persons in care.
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Type B
05/30/2024
Section Cited
HSC1569.696(a)

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All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component..

This requirement is not met as evidenced by:
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AD stated staff training will continue to be conducted to meet regulation requirement. AD will provide LPA with proof of staff training conducted via email by POC date.
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Based on record review, the licensee did not comply with the section cited above as staff have not completed required training, which poses a potential 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: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


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Document Has Been Signed on 04/30/2024 03:54 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 04/30/2024 at 03:28 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: 04/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2024
Section Cited
HSC
1569.69(a)(2)

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...the employee shall complete 10 hours of initial training... consist of 6 hours of hands-on shadowing training... completed prior to assisting with... medications, and 4 hours of other training or instruction... completed within the first two weeks of employment.
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AD stated staff training has been completed and will be documented to meet regulation requirement. AD will provide LPA with proof of staff training conducted via email by POC date.
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Based on record review, the licensee did not comply with the section cited above as staff shadowing training has not been documented, which poses a potential 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: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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