Jade Residential Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 3 staff were on duty, who contacted facility administrator (AD) Priscilla Celis about visit. AD Celis arrived at facility at 10:14 AM. As of 9/22/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the entrance of the facility and in the kitchen. The PUB475 "See Something, Say Something" poster was also observed at the entrance of the facility. LPA observed the Administrator's Certificate for Priscilla Celis, which expires on 07/07/2023, and Jeffrey Gonzales which expires on 12/14/2023. LPA De Perio toured the interior and exterior portions of the facility with AD Celis. The facility is a single level structure and is licensed for residents 60 years of age and over, of which 6 may be non-ambulatory, 0 bedridden and 6 hospice. For this visit, there are a total of 6 residents in care, of which 2 are on hospice. There are a total of 5 bedrooms, of which 2 are private, 1 shared male room, 1 shared female room and 1 staff bedroom. LPA De Perio toured each bedroom in the facility and observed all 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 2 restrooms of which 1 is for staff and 1 is for residents. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 106.7 degrees Fahrenheit and hand washing signs were also posted in each restroom. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked under the kitchen sink and is made inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the living room. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the garage. Medications were locked in a kitchen cabinet. Toxins were also observed to be locked in a cabinet located in the garage. Garage is also locked and made inaccessible to residents in care. For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which both were self-closing and self-latching. No bodies of water were observed. LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Celis. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPA De Perio discussed with AD Celis to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov. LPA De Perio discussed the California Code of Regulations Section 87466 Observation of the Resident and Section 87211 Reporting Requirements with AD Celis. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued. LPA De Perio advised AD Celis to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA. LPA De Perio conducted an exit interview with AD Celis and a copy of this report, and copies of the regulations discussed were provided to the facility.the state’s words, verbatim · CDSS document, Sep 22, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Ruth Martinez and announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at the facility was greeted and granted entry by Administrator. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (6) non-ambulatory, and (0) bedridden residents was submitted to CCL on 06/18/2021. Structure: The facility is a one-story house with an attached garage with 4 resident bedrooms, 1 caregiver bedroom, 1 living room, 1 dining room, and a restaurant style open kitchen, and 2 full bathrooms. The resident bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with 2 exit ways on each side of the house with shaded seating area for residents. Signal system: Central air/heating system installed with a central panel to control entire house. Bedrooms Residents: 4 Bedrooms are for 6 non-ambulatory residents. Bedrooms will accommodate 6 residents with 1 room being private rooms and 3 shared room. CONTINUED on LIC809-C Bedrooms Staff: 1 bedroom will be for live in staff. Bathrooms: All bathrooms have a working toilet, wash basin, walk in shower. Linens & Hygiene Supplies: Adequate supply of linen stored in hallway storage. Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week. Food Service: Adequate supply of 7-day non-perishable and 2-day perishables are to be stored in the kitchen. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational. Appliances: Electric four-burner stove, single oven, 1 refrigerator/freezer, dish washer, microwave, washer, dryer, and a spare refrigerator in garage are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents are stored in attached garage. Water Temperature: Tested and recorded the water temperature measures 114.8 Fahrenheit degrees in all restrooms. CONTINUED on LIC809-C Medications, First-Aid Kit & Book: Medication stored in storage cabinet with lock in kitchen inaccessible to residents. First aid kits are stored and located in office storage cabinet. Resident & Staff Files: Records will be kept locked in storage closet in office space. Pool/Jacuzzi & Pets: No bodies of water in facility. Fire Extinguisher: Mounted in wall in kitchen and entry way of office dated April 14, 2021. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the resident’s use, commensurate with the plan of operation. Fire clearance: Was approved on 09/15/2021. Component III: Conducted at the Pre-Licensing tele-visit, information provided about how to operate the facility within substantial compliance. All items reviewed during this visit are in compliance. Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor. Exit interview was conducted with Administrator and a copy of this report was left at facility.the state’s words, verbatim · CDSS document, Oct 28, 2021

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity:0006 Census (if any clients in care): COMP II by CAB successfully completed Method: Telephone call COMP II Participant: PATRICIA CELIS Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID . During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Oct 1, 2021