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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200466
Report Date: 11/13/2025
Date Signed: 11/13/2025 01:02:09 PM

Document Has Been Signed on 11/13/2025 01:02 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:
11/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Gina Rafael, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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
On 11/13/2025 at 8:35 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Gina Rafael, and explained the purpose of the visit. Administrator certificate is current.

LPA toured the facility including inside and out but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 5 bedrooms in total of which 4 bedrooms are occupied by the clients, 1 bedroom is occupied by staff, and one office space. There are no bodies of water. A comfortable temperature for clients is maintained at 74 degree Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the clients. All toilets, hand washing and bathing are safe and in operating condition. The supply of extra hygiene's was available for clients.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 11/13/2025. First aid kit was observed to be complete.

At 9:50 AM, 4 of clients’ records were reviewed. At 10:11 AM, 4 staff records were reviewed and 4 of 4 have current first aid training. LPA reviewed client's P&I money with log. LPA reviewed a sample of client's medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 12/01/2025:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility

Continue to LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 15
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 15
Document Has Been Signed on 11/13/2025 01:02 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/13/2025 at 11:56 AM
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: 11/13/2025

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having unlocked Thick-It medication, disinfecting wipes, scissors, vasaline, and duster spray which poses a potential safety risk to persons in care.
POC Due Date: 11/14/2025
Plan of Correction
1
2
3
4
The Administrator agrees to lock the items, self-certify the regulation with staff, and send proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 4 of 15
Document Has Been Signed on 11/13/2025 01:02 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/13/2025 at 11:56 AM
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: 11/13/2025

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed the living room screen net with holes, client’s shower with mold, bathroom vent filled with dust, cat feces, broken screen door, and door panels in the backyard which poses a potential safety risk to persons in care.
POC Due Date: 12/01/2025
Plan of Correction
1
2
3
4
The Administrator agrees to repair the screen net, clean the bathroom, and remove the items from the backyard. Proof of correction will be sent to CCLD by POC date.
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having two commodes blocking the emergency exit in C1’s room which poses a potential safety risk to persons in care.
POC Due Date: 12/01/2025
Plan of Correction
1
2
3
4
The Administrator agrees to self-certify the regulation with staff and send proof to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 5 of 15
Document Has Been Signed on 11/13/2025 01:02 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/13/2025 at 11:56 AM
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: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having the hot water temperature measured at 102.6 degrees Fahrenheit which poses a potential safety risk to persons in care.
POC Due Date: 11/17/2025
Plan of Correction
1
2
3
4
The Administrator agrees to have the water temperature measured within range and send proof to CCLD by POC date.
Type B
Section Cited
CCR
80072(a)(8)(B)
Personal Rights
(B) A written order from the client's physician indicating the need for the postural support shall be maintained in the client's record. The licensing agency shall be authorized to require additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based observation and record review, the licensee did not comply with the section cited above by having C1 with a safety belt on a wheelchair without a doctor’s order which poses a potential personal rights risk to persons in care.
POC Due Date: 12/04/2025
Plan of Correction
1
2
3
4
The Administrator agrees to obtain a doctor’s order and send an exception to the department by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 6 of 15
Document Has Been Signed on 11/13/2025 01:02 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/13/2025 at 11:56 AM
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: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not having enough nonperishable and perishable food for the clients which poses a potential health risk to persons in care.
POC Due Date: 11/21/2025
Plan of Correction
1
2
3
4
The Administrator agrees to purchase more food and send proof to CCLD by POC date.
Type B
Section Cited
CCR
80019(e)(3)
(3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and observation, the licensee did not comply with the section cited above by not having S4 associated with the facility which posed a potential safety risk to persons in care.
POC Due Date: 11/21/2025
Plan of Correction
1
2
3
4
The Administrator agrees to associate S4 and send proof to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 7 of 15
Document Has Been Signed on 11/13/2025 01:02 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/13/2025 at 12:08 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: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85068.4(g)
(g) If acceptance or retention of an individual 60 years of age or older would result in the number of persons 60 years of age or older exceeding 50 percent of the census in facilities with a capacity of six or fewer clients, or 25 percent of the census in facilities with a capacity over six, the licensee must request an exception in order to accept or retain the individual. The exception request must be made in accordance with Section 80024. The documentation specified in Section 85068.4(c) must be submitted with the exception request.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by having all the clients in care over the age of 60.
POC Due Date: 12/04/2025
Plan of Correction
1
2
3
4
The Administrator agrees to request an age exception request for two clients and send proof to CCLD by POC date.
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having a sufficient surety bond for clients' p&I money.
POC Due Date: 12/01/2025
Plan of Correction
1
2
3
4
The Administrator agrees to increase surety bond and/or spend down on clients' money. Proof of correction will be sent to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 12 of 15
Document Has Been Signed on 11/13/2025 01:02 PM - It Cannot Be Edited


Created By: Patricia Manalo On 11/13/2025 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: 11/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80077.3(a)(2)(j)
(j) Emergency fire and earthquake drills shall be conducted at least once every three months on each shift, and shall include all facility staff providing resident care and supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interviews, the licensee did not comply with the section cited above by not conducting emergency drills in 2025 which poses a potential safety risk to persons in care.
POC Due Date: 12/01/2025
Plan of Correction
1
2
3
4
The Administrator agrees to self certify the regulation with staff, conduct emergency drills, and send proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2025


LIC809 (FAS) - (06/04)
Page: 14 of 15
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: 11/13/2025
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
Continue from LIC809...

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:

At 9:09 AM, LPA observed Thick-It unlocked in the kitchen, disinfecting wipes, scissors, Vaseline, and duster unlocked in the cabinet.

At 9:13 AM, LPA observed the living room screen net with holes. At 9:19 AM, LPA observed the client's shower with mold and the bathroom vent filled with dust. At 9:45 AM, LPA observed cat feces, broken screen door, and door panels in the backyard.

At 9:15 AM, LPA observed two commode blocking the emergency exit in C1's room.

At 9:29 AM, LPA observed the hot water temperature measured at 102.6 degrees Fahrenheit.

At 10:37 AM, LPA observed the facility not having enough nonperishable food and fresh perishable food for the clients' in care.

At 11:09 AM, LPA observed C1 with a safety belt while on the wheelchair. Administrator will obtain a doctor’s order and send an exception.

At 11:30 AM, LPA observed that all the clients in care are over the age of 60 years old.

At 12:24 PM, LPA observed that the facility has not conducted emergency drills for 2025.

At 12:33 PM, LPA observed the facility's surety bond insufficient for clients' p&I money.

The Facility was 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.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC809 (FAS) - (06/04)
Page: 15 of 15