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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006062
Report Date: 10/11/2024
Date Signed: 10/11/2024 01:47:57 PM

Document Has Been Signed on 10/11/2024 01:47 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 ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JADE GUEST HOMEFACILITY NUMBER:
306006062
ADMINISTRATOR/
DIRECTOR:		DAO, BREVETFACILITY TYPE:
740
ADDRESS:2710 N. BERKELEY STTELEPHONE:
(714) 333-5363
CITY:ORANGESTATE: CAZIP CODE:
92865
CAPACITY: 6CENSUS: 3DATE:
10/11/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Leonor Gamolo - CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:04 PM
NARRATIVE
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LPA served amended report.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2024
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 10/11/2024 01:47 PM - It Cannot Be Edited


Created By: Dwayne L Mason On 10/11/2024 at 11:27 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: 10/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2024
Section Cited
CCR
87506(b)(2)

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Resident Records. 87506(b)Each resident’s record shall contain at least the following information: (2) Social Security number.
Based on record review, Licensee did not comply with the section cited above due to one resident's file not having a social security number documented.
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Facility staff stated they will ensure all resident files contain all of the information required by Title 22 867506(b) by the assigned POC due date. Facility staff stated all resident files will be accessible for review upon request.
Type B
10/18/2024
Section Cited
CCR
87468.1(a)(9)

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Personal Rights of Residents in All Facilities.
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately.
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Administrator stated they will conduct an in-service training with staff on record requests and fulfilling them. AD stated they will document the topics covered, staff attending, date/time of the training. AD stated they will send the above documentation to LPA via email by the assigned POC due date.
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Based on interviews conducted, the Licensee did not comply with the section cited above due to the Ombudsman's request for records not being fulfilled and no further communication regarding the request being made.
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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:Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024


LIC809 (FAS) - (06/04)
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