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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005502
Report Date: 07/21/2022
Date Signed: 07/21/2022 11:32:54 AM

Document Has Been Signed on 07/21/2022 11:32 AM - 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: 4DATE:
07/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jehla GabrielTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 05/10/2022. LPA was greeted and granted entry into the facility and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Care of Persons with Dementia, Inaccessible Items, has been cleared. Licensee secured noted items. Licensee has complied with the terms of the POC.



Licensee has been advised to maintain all items in compliance with Title 22 regulations.


Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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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