015601470-6-18-2024-15-AS-KNGN-D6D2UV-20240618174258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601470
Report Date: 06/18/2024
Date Signed: 06/18/2024 05:45:26 PM

Document Has Been Signed on 06/18/2024 05:45 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	J-SEI HOME		FACILITY NUMBER:	015601470
ADMINISTRATOR:	HART, MARY		FACILITY TYPE:	740
ADDRESS:	24954 CYPRESS AVENUE		TELEPHONE:	(510) 732-6658
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	14	CENSUS: 9	DATE:	06/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Ronilo Salvador, Administrator		TIME COMPLETED:	06:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/18/2024 at 11:30am, Licensing Program Analyst (LPA) Kelly Nguyen conducted an unannounced 1-Year Required inspection. LPA met with Administrator Ronilo Salvador (AD) and explained the purpose of the visit. The Administrator currently holds a certificate (#6067674740) that expires on 11/17/2025. The facility’s fire clearance was approved for fourteen (14) non-ambulatory residents. LPA toured the facility with AD including but not limited to bedrooms, bathrooms, kitchen, common area, and backyard. The facility consists of ten (10) total bedrooms, and four (4) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 111.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-slip matts. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 07/26/2023. Emergency Disaster Plan is posted. First aid kit was observed to be complete. LPA reviewed 5 staff files. LPA also reviewed 4 resident files which were, and sample 2 centralized medication. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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 6

Document Has Been Signed on 06/18/2024 05:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: J-SEI HOME	FACILITY NUMBER: 015601470
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(9)

General Food Service Requirements

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation LPA observed for are not being stored properly/ not being shield properly, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Administrator will provide an in-service training to staff on how to properly stored/ shield food properly and will email the training topics to CCLD by POC date.

Type B

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review LPA reviewed residents MAR that do not have a physician order for PRN and non-PRN medication.which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Administrator will review all residents MAR and make sure that it’s current with PRN/ non PRN with a physician orders and will email a self-certify of the understand of the regulation to CCLD by POC date.

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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 06/18/2024 05:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: J-SEI HOME	FACILITY NUMBER: 015601470
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(5)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review the licensee did not comply with the section cited above by not having resident updated physician report for resident prior readmitting to the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Administrator will review all residents physician report and have it up to date and email the update physician report to CCLD by POC date.

Type B

Section Cited

CCR

87507(d)

Admisson Agreements

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having update admission agreement for resident prior readmitting to the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	Administrator will obtain an update admission agreement of the resident to CCLD by POC date.

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: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: J-SEI HOME	FACILITY NUMBER: 015601470
	VISIT DATE: 06/18/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA observed the following deficiencies:

· At 12:00pm, LPA reviewed 4 staff recorded and 1 out of four does not have first aid and CPR certificate in files.
· At 1:30pm, LPA reviewed resident files that do not have an update admission agreement after being readmitted to the facility
· At 1:40pm, LPA reviewed resident files that do not have an updated physician report prior readmitting to the facility
· At 1:50pm, LPA reviewed residents MAR that do not have a physician order for PRN and non-PRN medication.
· At 3:00pm, LPA observed four unlocked knifes in kitchen cabinet.
· At 3:10pm, LPA observed dish detergent, arm&Hammer oxy clean, Ajax, pledge, drano, purell disinfectant, fabulso, d-molish are unlocked underneath the sink cabinet.
· At 3:15pm, LPA observed expired sandwich meat, and mold green/red bell pepper, and cucumber that create an odor in the refrigerator.
· At 3:25pm, LPA observed food are not being stored properly/ not being shield properly refrigerator/ freezer.
· At 3:45pm, LPA observed expired sandwich meat, and most of the perishable: green/red bell pepper, cucumber, cilantro, mushroom, green onion, and broccoli, either mold, or discoloration contain a bad odor.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

Page: 6 of 6