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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200464
Report Date: 11/30/2022
Date Signed: 11/30/2022 11:43:42 AM


Document Has Been Signed on 11/30/2022 11:43 AM - 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 & 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: 18DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Ho (Alan) Fung, AdminstratorTIME COMPLETED:
11:50 AM
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On 11/30/2022 at 9:50AM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct Infection Control Inspection. LPA met with Administrator, Ho (Alan) Administrator and explained the purpose of the visit.

LPA temperature were checked at the entrance. During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Water temperature is measure at 106-degree Fahrenheit. Fire extinguisher was last checked on 10/19/22. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

During record review, LPAs reviewed a sample of 2 staff records and observed 2 of 2 have health screening with TB test on file.

Report continue on LIC 809C...

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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: J & C CARE CENTER LLC
FACILITY NUMBER: 019200464
VISIT DATE: 11/30/2022
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/14/2022:

LIC 308 Designation of Administrative Responsibility

LIC 309 Administrative Organization

LIC 500 Personnel Report

LIC 610E Emergency Disaster Plan

Liability Insurance

Current Administrator’s Certificate

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly NguyenTELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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