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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200734
Report Date: 03/28/2023
Date Signed: 03/28/2023 01:45:11 PM


Document Has Been Signed on 03/28/2023 01:45 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:JOY SENIOR CENTERFACILITY NUMBER:
019200734
ADMINISTRATOR:MATHARU, GURPREETFACILITY TYPE:
740
ADDRESS:6400 BRENTWOOD BLVDTELEPHONE:
(510) 543-4695
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:18CENSUS: 13DATE:
03/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Gurpreet Matharu, Administrator TIME COMPLETED:
02:05 PM
NARRATIVE
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On this day 03/28/2023 at around 9:30AM, Licensing Program Analyst (LPA) L. Ibo arrived at the facility to conduct annual required inspection. LPA was met by caregiver S2. Administrator Gurpreet Matharu arrived around 12:30PM.

LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, dining and living areas. The facility has 11 bedrooms , 7 bathrooms and two shower rooms. There were 13 residents observed during the visit, some of them were in the living room, some of them were walking around the facility and some stayed in their own rooms. Two fire extinguisher was observed with service date December 2022.

Facility has sufficient supply of perishable and non-perishable foods. There were 3 staff working during the visit. Bathrooms and shower rooms were observed with grab bars and nonskid mats.

LPA reviewed 5 residents files and 3 staff files and interviewed 5 residents and 3 staff. Facility has wired carbon monoxide and smoke detector that were observed functional.

LPA observed the following:

At 10:00AM, LPA observed that S4’s fingerprint clearance was not associated to the facility.
At 12:10PM, LPA observed that R2 and R5 does not have updated needs and services plan.
At 12:15PM, LPA observed that R2 and R5 does not have updated LIC602A.

Deficiencies are being cited today in violation of California Code of Regulations and follows on 809D. Failure to submit proof of corrections (POC's) along with LIC9098 by plan of correction due dates may result in civil penalty. Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
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 03/28/2023 01:45 PM - It Cannot Be Edited

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: JOY SENIOR CENTER
FACILITY NUMBER: 019200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviEW, the licensee did not comply with the section cited above in Administrator failed to associate S4's fingerprint clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2023
Plan of Correction
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Cleared and corrected
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in administrator failed to update needs and services plan to R2 and R5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2023
Plan of Correction
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Administrator agreed to update R2 and R5's needs and services plan. A copy of new needs and service plan needs to be submitted to CCL 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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/28/2023 01:45 PM - It Cannot Be Edited

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: JOY SENIOR CENTER
FACILITY NUMBER: 019200734

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Administrator failed to update physician's report for R2 and R5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2023
Plan of Correction
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Administrator agreed to update R2 and R5's LIC602 by poc 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3