019200520-4-12-2023-15-AS-LFOA-CQTSBR-20230412134424

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200520
Report Date: 04/12/2023
Date Signed: 04/12/2023 01:44:35 PM

Document Has Been Signed on 04/12/2023 01:44 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:	JAYAR HOME		FACILITY NUMBER:	019200520
ADMINISTRATOR:	MEJIA, MARNIE		FACILITY TYPE:	735
ADDRESS:	576 JAYAR PLACE		TELEPHONE:	(510) 324-8343
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY: 4		CENSUS: 3	DATE:	04/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Marnie Mejia, Administrator		TIME COMPLETED:	02:00 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 4/12/2023 at approximately 9:15 am, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct annual required inspection. LPA was met by staff Jordan Cerro. LPA introduced self to staff and explained purpose of the visit. Nurse consultant Irene Monteclar arrived at the facility at around 9:30 am followed by Administrator Marnie Mejia. Upon arrival, LPA observed one client in the dining area working on an activity. Staff states the 2 other clients are at their respective day programs. The facility is a specialized residential home (SRH) and vendorized by Regional Center of the East Bay (RCEB). LPA inspected the facility inside and out including but not limited to 4 client rooms, bathrooms, dining area, kitchen and backyard. 3 out of 4 rooms are occupied. Temperature was observed comfortable at 72 degrees Fahrenheit. There was sufficient lighting and no bodies of water were observed. Carbon monoxide and smoke detector were tested and observed functional. Fire extinguisher appeared full and was last serviced on May 10, 2022. Hot water temperature in the shared clients’ bathroom and kitchen was measured at 122 degrees Fahrenheit. All toilets were observed with sanitizer, soap and paper towel. There is a 7-day supply of non perishable foods and 2-day supply of perishable foods observed. At around 10 am, LPA interviewed 2 staff. LPA attempted to interview clients. At approximately 10:30 am, LPA reviewed P & I money and log. *continuation on Lic 809C*

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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 4

Document Has Been Signed on 04/12/2023 01:44 PM - It Cannot Be Edited

Created By: Luisa Fontanilla On 04/12/2023 at 12:33 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: JAYAR HOME	FACILITY NUMBER: 019200520
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2023

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 in having cleaning chemicals (Chlorox, etc) unlocked under the sink which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/12/2023
	Plan of Correction
1 2 3 4	Administrator locked chemicals under the sink during the visit. Deficiency is cleared.

Type A

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 in having hot water temperature in the client bathroom and kitchen sink at 122 F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/12/2023
	Plan of Correction
1 2 3 4	Adminsitrator adjusted hot water temperature to 119 F during the visit. Deficiency is cleared.

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:

Luisa Fontanilla

LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 04/12/2023 01:44 PM - It Cannot Be Edited

Created By: Luisa Fontanilla On 04/12/2023 at 12:33 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: JAYAR HOME	FACILITY NUMBER: 019200520
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2023

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 in failing to maintain fence in good repair which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed fence is missing wood planks and leaning toward's the next door neighbor's side.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	BY POC date, Administrator will send LPA photo proof of repaired fence.

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.

SUPERVISOR'S NAME:

Yvonne Flores-Larios

LICENSING EVALUATOR NAME:

Luisa Fontanilla

LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: JAYAR HOME	FACILITY NUMBER: 019200520
	VISIT DATE: 04/12/2023

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

LPA observed facility has sufficient amount of surety bond to cover amount of money being handled at one time.

At approximately 10:45 am, LPA reviewed medications and Medication Administration Record (MAR) with Nurse Consultant.

At around 11:20 am, LPA reviewed 2 out of 3 client records and 4 staff files. All staff are fingerprint cleared and have current First Aid and CPR training.

Last fire drill was conducted on 3/18/2023.

LPA observed the following deficiencies:

At approximately 9:25 am, LPA observed chemicals under the sink unlocked
At approximately 10 am, LPA measured hot water temperature in bathroom and kitchen at 122 degrees Fahrenheit
At approximately 11 am while inspecting the backyard, LPA observed missing wood planks on the fence. Fence was observed leaning towards the next door neighbor's house.

Deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Exit interview was conducted with Administrator. Appeal Rights and a copy of this report was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4