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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006062
Report Date: 11/21/2024
Date Signed: 11/21/2024 04:29:03 PM

Document Has Been Signed on 11/21/2024 04:29 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 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:
11/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Juanita Marvin-CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:44 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Brandon Lopez conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit, and were greeted and granted entry by Caregiver Juanita Marvin. Administrator (AD) Brevet Dao was notified via telephone by staff. AD arrived at approximately 3:45 pm.

For today’s visit, LPAs observed a total of three residents in care and one staff member on duty. LPAs observed the Administrator Certificate for Administrator Assistant Ladyjean Veracruz which expires on June 01, 2026.

LPAs toured the interior and exterior portions of the facility with caregiver Marvin. The facility is a single level structure and is licensed for six non-ambulatory residents of which five may be on hospice and two bedridden. There are a total of four bedrooms, of which three are resident bedrooms, and one private bedroom for staff. During the tour LPAs observe the 20"x26" complaint poster (PUB 475) located by the entryway. LPAs toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of two restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars were provided. LPAs observed that two of two restrooms do not have non-skid floor mats; a Deficiency was issued. Water temperature tested between 106.3-110.6 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were observed to be unlocked in a kitchen drawer; a Deficiency was issued. Fire extinguisher was charged and located by the kitchen. Fire extinguisher was last service on June 18, 2024.

CONTINUED ON LIC809-C...

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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 GUEST HOME
FACILITY NUMBER: 306006062
VISIT DATE: 11/21/2024
NARRATIVE
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LPAs observed the emergency disaster and evacuation plan which is located by the entryway. Facility had back-up emergency food and water. LPAs observed that the First Aid Kit had all the required components. LPAs observed that medications were locked and inaccessible to residents in care.
During the tour LPAs observed a Comex bleach powder cleaner and a liquid bleach cleaner on the first restroom, next to the living room; a Deficiency was issued. Chemicals were observed to be unlocked.

For the exterior portion, LPAs observed a shaded area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard, which both is self-closing and self-latching. No bodies of water were observed.

LPAs reviewed three resident files and two staff files. LPAs reviewed the Medication Administrator Record (MAR) for Resident 1 (R1). Per preplacement appraisal dated 10/21/23 under Services Needed it states that Resident 1 (R1) needs help with medication. LPAs observed that PM Buspirone 5mg and PRN Hydrocodone-Acetamin were out of pills; a

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Ladyjean Veracruz.

A copy of this report and Appeal Rights were provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 11/21/2024 04:29 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 11/21/2024 at 03:47 PM
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: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During the tour LPAs observed knives and scissors in an unlocked kitchen drawer. Per caregiver she locks the knives in the staff bedroom at night.
POC Due Date: 11/22/2024
Plan of Correction
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During the visit Licensee locked the knives in a locked cabinet located under the kitchen sink.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/21/2024 04:29 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 11/21/2024 at 03:47 PM
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: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed a shower chair; however LPA did not observe a non-skid floor mat in two of two restrooms.
POC Due Date: 11/28/2024
Plan of Correction
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Licensee to provide non-skid mats for the restrooms and email LPA proof by POC due date.
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPAs observed a Comex bleach powder cleaner and a liquid bleach cleaner on the first restroom, next to the living room. Chemicals were observed to be unlocked.
POC Due Date: 11/28/2024
Plan of Correction
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During the visit Licensee moved the chemicals to a locked cabinet under the kitchen sink.
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:Sheila Santos
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/21/2024 04:29 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 11/21/2024 at 03:47 PM
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: 11/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87464(d)
Basic Services
(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Per preplacement appraisal dated 10/21/23 under Services Needed it states that Resident 1 (R1) needs help with medication. LPA observed that PM Buspirone 5mg and PRN Hydrocodone-Acetamin were out of pills.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee to follow-up on the R1 medications refills and email proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5