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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006029
Report Date: 12/04/2024
Date Signed: 12/04/2024 12:04:36 PM

Document Has Been Signed on 12/04/2024 12:04 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JADE RESIDENTIAL CAREFACILITY NUMBER:
306006029
ADMINISTRATOR/
DIRECTOR:
GONZALES, JEFFREYFACILITY TYPE:
740
ADDRESS:11821 FLAMINGO DR.TELEPHONE:
(949) 573-6489
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY: 6CENSUS: DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Michael Tea and Fred Arias conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. At around 8:00 AM, LPA Tea and Arias were greeted and granted entry into the facility by caregivers Lucita Rodriguez and Urcena Pepito and explained the reason for the visit. The administrator (AD) Priscilla Celis arrived shortly to assist with the visit. The facility is licensed for six non-ambulatory residents with a hospice waiver for six. Currently there are six residents and one resident on hospice.

Around 8:10 AM, LPAs Tea and Arias reviewed six resident files and two staff files. Resident files and staff files contained all required documentation. Upon review of records, the facility is up to date with required quarterly emergency disaster drills, which was last conducted on November 4, 2024. The last disaster drill was not documented or logged, LPA address to AD and staff to document drills right away. AD Celis’s administrator certificate has an expiration date of July 1, 2025.

LPAs Tea and Arias along with AD Celis toured the facility at 9:14 AM. LPAs toured the physical plant, checked food service, and the first aid kit. The facility is a one-story home, the home consists of 4 resident bedrooms, 1 staff room, 2 bathrooms, living room, dining room, kitchen, sunroom/office area and attached garage. LPAs observed smoke detectors/carbon monoxide in common areas and bedrooms are operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. Water temperature measured between around 76 F degrees and 127.5 F degrees. Staff adjusted the water temperature when it was high, and the temperature became really low due to the usage of the laundry machine. LPA explained that water temperature needs to be between 105 F degrees to 120 F degrees to meet department standards. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected.

Annual continuation on LIC809-C

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JADE RESIDENTIAL CARE
FACILITY NUMBER: 306006029
VISIT DATE: 12/04/2024
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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPAs observed sharps and toxins locked and inaccessible to residents underneath the kitchen sink. LPAs also observed toxin substances secured in cabinets in the garage as well.

The fire extinguishers are fully charged throughout the facility. Kitchen appliances are operational during today's visit. LPAs toured the outside grounds and there is ample seating underneath a shaded patio area in the backyard. There are two exit gates that are self-latching and operational on both sides of the house. LPAs observed PPE supplies, emergency food and water stored in the garage. Facility provides activities based on their personal choice. Residents play bingo and other games, exercise and do music therapy. At the time of the visit, LPAs observed residents lounging in the living room watching tv and having breakfast and lunch.

At 9:40 AM LPAs reviewed medication storage and administration. Medications are stored in a locked cabinet in the kitchen area. Medications are being administered per physician order, but LPAs advise on better documentation and methods of dispensing medication, specifically bubble packs. LPAs interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator Priscilla Celis and a copy of this report LIC809, along with the 809-C, LIC858, and LIC859 were read and provided to the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024
LIC809 (FAS) - (06/04)
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