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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200245
Report Date: 02/07/2024
Date Signed: 02/07/2024 05:22:09 PM

Document Has Been Signed on 02/07/2024 05:22 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:
02/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Erich Solomon/Staff and
Michael Wise/Administrator		TIME COMPLETED:
05:25 PM
NARRATIVE
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At 11:50 a.m. on this day, February 7, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Erich Solomon. and informed the reason for visit. LPA called and spoke over the phone with Michael Wise, administrator. LPA also spoke with Maria Ingco, licensee. Administrator arrived at around 12:20 p.m.

Administrator submitted the facility's Infection Control Plan which LPA received on February 6, 2024.

LPA toured the facility inside out. LPA inspected the kitchen, dining area, living and family rooms. bedrooms, bathrooms, side yard and backyard. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and storage for cleaning supplies were observed locked. Facility has hygiene supplies for residents' use.

Facility has carbon monoxide and smoke detectors that were tested, and observed functional. Facility conducts fire drills and records showed last conducted December 20, 2023. Fire extinguisher checked, observed fully charge with tag showed serviced January 22, 2024. Hot water temperature was tested in one of the bathrooms and measured at 113 degrees Fahrenheit..

LPA reviewed 3 staff and 2 residents records, and interviewed 2 staff and 2 residents. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Record. P&I were checked and compared with the last recorded balance.


....continued on 809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 02/07/2024
NARRATIVE
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Licensee to submit the following current/updated documents by 2/21/24:
1. LIC500 Personnel Report
2. LIC610D Emergency Disaster Plan (9 pages)
3. Proof of Surety Bond coverage

LPA observed the following:
-at 12:30 p.m., Michael Wise's administrator certificate expired. According to Mr. Wise, he is in the process of renewing his certificate.
-at 2:00 p.m., staff (S3) is not associated to the facility. LIC9182 on file showed not completely filled-up.
-at 3:30 p.m., residents' (R1 and R2) LIC625 Appraisal/Needs and Services Plan are over 5 years old.
-at 3:40 p.m., R1 and R2 do not have LIC9172 Functional Capacity Assessment.

Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties.

Deficiencies and plan and proof of corrections were discussed.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
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Document Has Been Signed on 02/07/2024 05:22 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/07/2024 at 04:40 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JERRI'S ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 019200245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069.2(b)
Functional Capabilities Assessment
(b) Assessment of the client's need for assistance shall include consideration of his/her physical condition affecting participation in his/her own care, including:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on records review, the licensee did not comply with the section cited above in 2 out of 2 residents not having LIC9172 Functional Capability Assessment on file which poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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2
3
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Administrator to complete the LIC9172s and submit copies by 2/21/24.
Type B
Section Cited
CCR
85068.3(a)
85068.3 Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 2 out of 2 residents' LIC625 over 5 years old which pose a potential health and/or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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Administrator to update the LIC625 snd submit self-certification they are completed by 2/21/24.
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
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/07/2024 05:22 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/07/2024 at 04:58 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JERRI'S ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 019200245

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(c)(e)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(3) Request a transfer of a criminal record clearance as specified in Section 80019(f)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above for S3 not associated to the facillity which poses a potential safety risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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Administrator to submit the complete transter request by 2/21/24.
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:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


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