<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200464
Report Date: 12/10/2021
Date Signed: 12/10/2021 05:51:00 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2021 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210309151639
FACILITY NAME:J & C CARE CENTER LLCFACILITY NUMBER:
019200464
ADMINISTRATOR:CHING, JESSICAFACILITY TYPE:
740
ADDRESS:4240 REDDING STREETTELEPHONE:
(510) 482-0108
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:25CENSUS: 23DATE:
12/10/2021
UNANNOUNCEDTIME BEGAN:
07:55 AM
MET WITH:Jessica Ching, AdministratorTIME COMPLETED:
06:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not provide adequate food service.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/10/2021 at 7:55am Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the allegation that Staff does not provide adequate food service to deliver investigation findings. LPA met with Administrators Jessica Ching and Ho Fung, and explain the purpose of the visit.

LPA toured the dinning room and observed one pancake and a cup of milk or coffee were being served to residents as the meal of breakfast.



(Continue on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 15-AS-20210309151639
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 & C CARE CENTER LLC
FACILITY NUMBER: 019200464
VISIT DATE: 12/10/2021
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
Upon investigation, the Department interviewed Residents (R), multiple residents stated that no snake was provided between meal times, R1 stated that he bought his own snacks or give money to Administrator to buy food for him. R7 stated if he was hungry then waited for meal time. Staff (S), S3 stated that she has never told to make snacks for residents.

The Department reviewed 4 Menus and found that breakfast did not match the Menu this morning. Menu shows Cereal, Scrambled Eggs, Fruit Juice and Coffee/Milk but residents were served one pancake and coffee/milk. S3 stated that scrambled eggs and bacon listed on menus were rarely made. Residents claimed that they have never seen the menu or did not know there was menu at the facility.

Based on interviews and records review, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

The following deficiency (LIC 9099-D) was cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.


Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2021 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210309151639

FACILITY NAME:J & C CARE CENTER LLCFACILITY NUMBER:
019200464
ADMINISTRATOR:CHING, JESSICAFACILITY TYPE:
740
ADDRESS:4240 REDDING STREETTELEPHONE:
(510) 482-0108
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:25CENSUS: 23DATE:
12/10/2021
UNANNOUNCEDTIME BEGAN:
07:55 AM
MET WITH:Jessica Ching, AdministratorTIME COMPLETED:
06:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility lacks adequate supplies needed to care for residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/10/2021 at 7:55am Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the allegation that Facility lacks adequate supplies needed to care for residents to deliver investigation findings. LPA met with Administrators Jessica Ching and Ho Fung, and explain the purpose of the visit.

Upon investigation, the Department interviewed staff, residents, and reviewed files, and was unble to identify what type of supplies needed to care for residents was lacking. Therefore, the above allegation is found to be UNFOUNDED

Exit interview conducted, and a copy of this report provided..
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2021 and conducted by Evaluator Catherine Lin
COMPLAINT CONTROL NUMBER: 15-AS-20210309151639

FACILITY NAME:J & C CARE CENTER LLCFACILITY NUMBER:
019200464
ADMINISTRATOR:CHING, JESSICAFACILITY TYPE:
740
ADDRESS:4240 REDDING STREETTELEPHONE:
(510) 482-0108
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:25CENSUS: 23DATE:
12/10/2021
UNANNOUNCEDTIME BEGAN:
07:55 AM
MET WITH:Jessica Ching, AdministratorTIME COMPLETED:
06:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has inadequate toiletry supplies.
Facility has inadequate staffing.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/10/2021 at 7:55am Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigations regarding the allegations that Facility has inadequate toiletry supplies and Facility has inadequate staffing to deliver investigation findings. LPA met with Administrators Jessica Ching and Ho Fung, and explain the purpose of the visit.

Upon entrance, LPA toured the facility bathrooms, toilet paper, shampoo, hand soaps and toothpaste were observed but paper towel. Administrator stated that some residents took paper towels away or throw into toilet. Upon investigation, the Department interviewed residents, multiple residents stated when they asked for paper towels or other toiletries, facility would provide to them. The Department interviewed staff and residents, reviewed staff roster and work schedules to found that 3-4 staff were scheduled in day time, 1-3 staff were scheduled at night time. Residents stated when they needed assistance, staff were always there to help.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20210309151639
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 & C CARE CENTER LLC
FACILITY NUMBER: 019200464
VISIT DATE: 12/10/2021
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
Although the allegations may have happened or are valid, there are not preponderance of evidence to provide the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted, and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20210309151639
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 & C CARE CENTER LLC
FACILITY NUMBER: 019200464
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2021
Section Cited
CCR
87555(a)
1
2
3
4
5
6
7
87555 General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents….
1
2
3
4
5
6
7
1. Administrator agreed to post the menu in both English and Chinese versions in the hallway and kitchen, and follow through, and submit photos to CCL by POC due date.
2. Administrator agreed to provide snacks between meal times.
8
9
10
11
12
13
14
Based on investigation, the licensee did not comply with the section cited above, where facility did not provide adequate food which posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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 FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6