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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200520
Report Date: 09/06/2024
Date Signed: 09/06/2024 02:17:04 PM

Document Has Been Signed on 09/06/2024 02:17 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 HOMEFACILITY NUMBER:
019200520
ADMINISTRATOR/
DIRECTOR:		ALCANTARA, MARIAFACILITY TYPE:
735
ADDRESS:576 JAYAR PLACETELEPHONE:
(510) 324-8343
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 4CENSUS: 4DATE:
09/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Irene Monteclar, Nurse consultant TIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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On 9/6/2024 at approximately 12:50PM, Licensing Program Analyst (LPA) K. Nguyen arrived unannounced to conduct annual required inspection. LPA was met by staff Emy Yong. LPA introduced self to staff and explained purpose of the visit.

Nurse consultant Irene Monteclar arrived at the facility at around 1:00 pm. Administrator was not available during visit. LPA observed one client watching T.V. inside his room. 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).

Upon arrival LPA observed facility bathroom is under construction, due to a water damage to the flooring. 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 April 15, 2024. Hot water temperature in the shared clients’ bathroom and kitchen was measured at 105 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.

Report continued on LIC on 809c...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2024
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 09/06/2024 02:17 PM - It Cannot Be Edited


Created By: Kelly Nguyen On 09/06/2024 at 02:03 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: 09/06/2024

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 by having chemicals under the sink unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2024
Plan of Correction
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Staff locked chemical during inspection. Deficiency Clear
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:Bennett Fong
LICENSING EVALUATOR NAME:Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024


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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: JAYAR HOME
FACILITY NUMBER: 019200520
VISIT DATE: 09/06/2024
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At around 1:20 pm LPA attempted to interview client. At approximately 1:30 pm, LPA reviewed P & I money and log.

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



At approximately 1:30 pm, LPA reviewed medications and Medication Administration Record (MAR) with Nurse Consultant.

At around 1:45 pm, LPA reviewed 4 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 8/18/2024.

LPA observed the following deficiency:

· At approximately 1:10 pm, LPA observed chemicals under the sink unlocked

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: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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