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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200466
Report Date: 11/07/2024
Date Signed: 11/07/2024 01:11:07 PM

Document Has Been Signed on 11/07/2024 01:11 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JADE'S HOMEFACILITY NUMBER:
019200466
ADMINISTRATOR/
DIRECTOR:		RAFAEL, GINAFACILITY TYPE:
735
ADDRESS:4443 ALAMEDA DRIVETELEPHONE:
(408) 206-7301
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 4CENSUS: 4DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Gina Rafael, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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On 11/07/2024 at 9:00 AM, Licensing Program Analysts (LPAs) P. Manalo and Y. Flores-Larios arrived unannounced to conduct 1-Year Annual Required inspection. LPAs met with Administrator, Gina Rafael and explained the purpose of the visit. Administrator certificate is current and administrator number is 7032756735. The facility’s fire clearance was approved for all four (4) may be non-ambulatory.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 6 total bedrooms which 4 bedrooms are occupied by the clients, 1 bedroom is occupied by staff, and one office for administrator. There are no bodies of water. A comfortable temperature for clients is maintained at 71 degree Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 111.3 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene's was available for clients. There is a minimum of one week supply of nonperishable and 2-day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 05/15/2024. First aid kit was observed to be complete. Emergency Disaster Drill was last conducted on 04/09/2024.

At 10:00 am, 4 of clients records were reviewed. At 11:00 am, 4 staff records were reviewed and 4 of 4 have current first aid training and 4 of 4 associated to the facility. LPAs reviewed client's P&I money with log and there was no discrepancies observed. LPAs reviewed a sample of client's medications. All records were observed to be complete and up to date.

Continue to LIC809C...
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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Document Has Been Signed on 11/07/2024 01:11 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/07/2024 at 12:11 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: JADE'S HOME
FACILITY NUMBER: 019200466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 having unlocked cleaning supplies in the staff and client's bathroom which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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During the inspection staff removed the cleaning supplies and locked it during the vist. POC cleared on this date.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/07/2024 01:11 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/07/2024 at 12:11 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: JADE'S HOME
FACILITY NUMBER: 019200466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

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 having a commode and hamper blocking R1, R2, and R4's fire exit door which poses a potential health and safety risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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The administrator removed the items. POC cleared during the visit.
Type B
Section Cited
CCR
80076(a)(1)
(a) In facilities providing meals to clients, the following shall apply: (1)All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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 having pancake mix that is best used by 10/18/2022 which poses a potential health and safety risk in care.
POC Due Date: 11/08/2024
Plan of Correction
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The administrator agrees to remove the food item from the pantry. POC cleared during the visit.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/07/2024 01:11 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/07/2024 at 12:28 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: JADE'S HOME
FACILITY NUMBER: 019200466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80025(c)
(c) The amount of the bond shall be according to the following schedule:

AMOUNT SAFEGUARDED PER MONTH BOND REQUIRED

$750 or less $1,000
$751 to $1,500 $2,000
$1,501 to $2,500 $3,000

Every further increment of $1,000 or fraction thereof shall require an additional $1,000 on the bond.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the administrator did not comply with the section cited above for not having sufficient Surety Bond coverage for the total P&I facility handles at a time which poses a potential personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator agrees to review client's P&I and spend down to be within current bond range, obtain a new surety bond and submit proof to CCLD by 11/15/2024 .
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Patricia Manalo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2024


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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: JADE'S HOME
FACILITY NUMBER: 019200466
VISIT DATE: 11/07/2024
NARRATIVE
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Continue from LIC809...

Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 11/15/2024:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610 Emergency Disaster Plan

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Patricia Manalo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC809 (FAS) - (06/04)
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