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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200245
Report Date: 02/27/2023
Date Signed: 02/27/2023 02:02:24 PM

Document Has Been Signed on 02/27/2023 02:02 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:JERRI'S ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
019200245
ADMINISTRATOR:MICHAEL WISEFACILITY TYPE:
735
ADDRESS:24615 PATRICIA CT.TELEPHONE:
(510) 583-0521
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 3CENSUS: 2DATE:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Erich Solomon/Staff and
Michael Wise/Administrator		TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Delmundo conducted an unannounced annual/infection control inspection. LPA met with staff, Erich Solomon, and informed the purpose of visit. LPA called and spoke with Michael Wise, administrator, who arrived after about 50 minutes.

Facility has an approved LIC808 Mitigation Plan. Facility has not submitted the LIC9282 Infection Control Plan.

LPA toured the facility inside out with Erich Solomon. LPA inspected the living room, dining area, family room, kitchen, hallways, residents bedrooms, side and backyard. There's adequate food supplies of perishables good for 2 days and non-perishables good for 7 days. Central storage for medications and cabinets for cleaning supplies were observed locked.

LPA observed screening station by the front entrance with hand sanitizer, no touch temperature probe. Facility has Visitor's log. Temperature and symptom checks are done at the entrance. Facility keeps record of proof of vaccination of residents and staff. Supplies of PPEs checked. Facility has antigen test kits readily available. COVID-19 signages were observed in some areas of the facility. Bathroom lavatories were observed with liquid soap. Trash cans were observed with no touch lids.

Fire extinguisher checked, and observed fully charge with tag showed serviced January 9, 2023. Hot water temperature in one of the common bathrooms was teste,d and measured at 111.8 degrees Fahrenheit.

.......continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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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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: JERRI'S ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 019200245
VISIT DATE: 02/27/2023
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LPA observed the following:
1. Paper towel in one of the bathrooms not on a dispenser.
2. No "Wear Mask" and Covid-19 signages on the front door and in the living room.
3. No supply of face shields.
4. Staff not wearing mask.

Administrator to submit the following by March 13, 2023:
1. LIC308 Designation of Facility Responsibility
2, LIC500 Personnel Report
3. LIC610D Emergency Disaster Plan (9 pages)
4. N95 fit testing records/certificates
5. LIC9282 Infection Control Plan

No citation issued.

Exit interview conducte, and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC809 (FAS) - (06/04)
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