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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200245
Report Date: 02/05/2025
Date Signed: 02/05/2025 04:08:40 PM

Document Has Been Signed on 02/05/2025 04:08 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/
DIRECTOR:		INGCO, MARIAFACILITY TYPE:
735
ADDRESS:24615 PATRICIA CT.TELEPHONE:
(510) 583-0521
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 3CENSUS: 2DATE:
02/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Erich Solomon/Staff and
Michael Wise/Residential Manager		TIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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At 12:35 pm, on this day, February 5, 2025, 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 Maria Ingco, administrator, and Michael Wise, residential manager (RM). RM arrived at around 1:30 pm.

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 observed functional. Facility conducts fire drills, however, record showed last conducted July 9, 2024. Fire extinguisher checked, observed fully charge with tag showed serviced January 29, 2025. Hot water temperature was tested in one of the bathrooms and measured at 106.7 degrees Fahrenheit.

LPA reviewed 4 staff and 2 residents records, and interviewed 1 resident. Medications were checked and compared with doctor's order and LIC622 Centrally Stored Medication and Destruction Records. 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: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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: 02/05/2025
NARRATIVE
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Administrator to submit the following current/updated documents by 2/19/25:
1. LIC500 Personnel Report
2. LIC610D Emergency Disaster Plan (9 pages)
3. Proof of Surety Bond coverage

LPA observed the following:
-at 12:59 pm, piece of wood, broken chair, dented/broken trash can in the side yard.
-at 1:00 pm, chair cushions in the backyard wet and with mold.
-at 1:30 pm, fire drill record showed last conducted July 9, 2024.
-at 2:50 pm, residents' (R1 and R2) Tylenol do not have dosage in the medication labels.

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 with the administrator over the phone in the presence of RM.

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: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/05/2025 04:08 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/05/2025 at 02:30 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: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 in the following pose a potential safety and/or personal rights risk to persons in care: piece of wood, broken chair, dented/broken trash can in the side yard; chair cushions in the backyard wet and with mold.
POC Due Date: 02/19/2025
Plan of Correction
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Administrator to have the yard cleaned and discard the chair cushions. Pictures to be submitted by 2/19/25.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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 in not doing the drill as required which poses a potential safety and/or personal rights risk to persons in care.
POC Due Date: 02/19/2025
Plan of Correction
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2
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Admnistrator to have the drill conducted and submit copy by 2/19/25.
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: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/05/2025 04:08 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 02/05/2025 at 03:39 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: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)(2)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) 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 client'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: (2) The exact dosage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and records review, the licensee did not comply with the section cited above in 2 residents' medication labels with no dosage which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date: 02/06/2025
Plan of Correction
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Corrected.
Residential manager checked with the pharmacist and obtained the correct labels while LPA was at the facility.

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: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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