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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005502
Report Date: 05/24/2021
Date Signed: 05/24/2021 03:00:03 PM

Document Has Been Signed on 05/24/2021 03:00 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 2FACILITY NUMBER:
306005502
ADMINISTRATOR:PAO, WESLEYFACILITY TYPE:
740
ADDRESS:20152 RIVERSIDE DRTELEPHONE:
(424) 270-4452
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 6CENSUS: 5DATE:
05/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:18 PM
MET WITH:Mary Joy Garcia and Jehla Rose GabrielTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Mary Joy Garcia and explained the reason for the visit. Licensee Jehla Rose Gabriel arrived during the visit.

At 12:35 PM, LPA toured the facility with Caregiver Mary Joy Garcia. Facility has 5 residents in care during today's visit. LPA observed and spoke with residents in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Three rooms are single occupancy and one room is currently double occupancy. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet. Facility takes resident temperatures daily. Facility has covid precaution postings as well as all required department postings. Facility to submit mitigation plan to the department. LPA observed the emergency disaster plan posted in facility. LPA observed adequate emergency food and water as well as the first aid kit. LPA toured the outside grounds and observed the shaded outside visitation area. Exit gate is unlocked and self latching. LPA observed a free standing back house in the yard. LPA observed the locked medication storage area. Facility has ample supply of surgical masks and gloves as well as cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19.
During the visit, LPA consulted with Licensee regarding the importance of maintaining a thirty day supply of all PPE as well as having hand washing signs in all the restrooms.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report will be emailed to Administrator due to technical difficulties.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2021
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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