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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200371
Report Date: 09/08/2021
Date Signed: 09/08/2021 03:32:19 PM

Document Has Been Signed on 09/08/2021 03:32 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:J&J PLACEFACILITY NUMBER:
079200371
ADMINISTRATOR:JACQUELINE TAPIAFACILITY TYPE:
735
ADDRESS:2826 FORTUNA COURTTELEPHONE:
(925) 978-4381
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 5DATE:
09/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Ruby Ortiz, CaregiverTIME COMPLETED:
03:40 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 09/08/2021 at 02:25PM. Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Ruby Ortiz, Caregiver and explained the purpose of the visit. LPA spoke with Administrator/Licensee Jacqueline Tapia, via telephone. Administrator/Licensee gave approval for Caregiver to sign documents.

Upon entry, LPA's temperature was checked LPA observed screening station that contained hand sanitizer and surgical masks. LPA toured facility including but not limited to common areas, bathrooms, kitchen, and backyard. LPA observed cough etiquette and physical distancing signs posted in the common areas. All hand washing stations were equipped with soap, paper towel, garbage can with a lid, and hand washing posters were posted.

During record review, LPA observed visitors log and temperature log for residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed PPE, food, and paper supplies are sufficient.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2021
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 1