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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006062
Report Date: 10/17/2022
Date Signed: 10/17/2022 11:41:38 AM

Document Has Been Signed on 10/17/2022 11:41 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:JADE GUEST HOMEFACILITY NUMBER:
306006062
ADMINISTRATOR:DAO, BREVETFACILITY TYPE:
740
ADDRESS:2710 N. BERKELEY STTELEPHONE:
(714) 507-8040
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 6DATE:
10/17/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rebecca Litawen, caregiver
Brevet Dao, Administrator		TIME COMPLETED:
11:30 AM
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On 10/17/2022, Licensing Program Analyst (LPA) conducted an unannounced visit to the facility for the purpose of following up on the plan of corrections resulting from the annual inspection visit led on 10/14/2022. LPA was greeted and granted entry by caregiving staff after explaining the purpose of the visit.

At approximately 11:00am, LPA requested caregiver to demonstrate where the cleaning supplies are currently stored. Caregiver shown the storage under the sink is still in use and has not been equipped with any securing device at the time of this visit. No cleaning supplies are stored in the laundry closet at this time.

At approximately 11:05am, LPA requested caregiver to show the medication storage. Centrally stored medication is adequately stored in a secure closet in the hallway leading to the bedrooms.

Residents are observed in the common areas or relaxing in their bedrooms and have all adequately been dressed as per their request.

Three of the four type A violations observed on 10/14/2022 are cleared at this time. However a deficiency remains in effect in regard to the safe storage of cleaning supplies and toxic substances. An immediate civil penalty for failure to correct the deficiency observed on 10/14/2022 and confirmed on 10/17/2022 is assessed.

LPA conducted an exit interview, reviewed the report with the facility staff and left a copy of the report along with appeal rights at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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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Document Has Been Signed on 10/17/2022 11:41 AM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 10/17/2022 at 11:22 AM
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: JADE GUEST HOME
FACILITY NUMBER: 306006062

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2022
Section Cited
CCR
87705(f)

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The California Code of Regulations Section 87705(f) relative to the Care of Persons with Dementia indicates that: "The following shall be stored inaccessible to residents with dementia: (...) nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances"
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Licensee will ensure that all potentially dangerous items are stored securely within the next 24 hours.
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This requirement is not met as evidenced by: LPA observed cleanings solutions left unsecured in the cabinet under the sink.
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022


LIC809 (FAS) - (06/04)
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