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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200706
Report Date: 02/10/2023
Date Signed: 02/10/2023 12:46:29 PM

Document Has Been Signed on 02/10/2023 12:46 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&M RESIDENTIAL CAREFACILITY NUMBER:
079200706
ADMINISTRATOR:RODRIGUEZ, JOSEFACILITY TYPE:
735
ADDRESS:2831 VISTA WAYTELEPHONE:
(925) 529-0923
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 6DATE:
02/10/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Olivia Gonzalez, House ManagerTIME COMPLETED:
12:50 PM
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On 2/10/2023 at 12:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint. LPA met with Olivia Gonzalez, House Manager and explained the reason for the visit.

Upon arrival, LPA observed total of two (2) staff S2, S3, one (1) client in the common area, and one (1) client in the bedroom. LPA was informed that the other four (4) clients were at the day program.

During the health and safety check, LPA toured the building with House Manager including but not limited to common areas, bathrooms, bedrooms and outdoor area. Facility is noted to be clean and in good repair and clients in care appear to be safe. There are no imminent health/safety concerns on today's date.

No deficiencies were cited today.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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