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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200706
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:52:32 PM

Document Has Been Signed on 09/10/2024 12:52 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/
DIRECTOR:		RODRIGUEZ, JOSEFACILITY TYPE:
735
ADDRESS:2831 VISTA WAYTELEPHONE:
(925) 529-0923
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 4DATE:
09/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Olivia Gonzalez, House ManagerTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 9/10/2024 at 11:40am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 9/9/2024. LPA met with Olivia Gonzalez, House Manager, and explained the purpose of the visit. Administrator Jose Rodriguez, arrived at 12:18pm.

The incident occurred on 9/6/2024, which involved a staff hitting a client. S2 stated a witness reported they witnessed the staff hit the client during an outing. The facility conducted their own investigation and the staff admitted in being frustrated with the client, but did not recall clearly if he hit the client, but did admit pulling, pushing, and shoving was involved. The facility terminated the staff.

S2 scanned the following documents to LPA: S3's termination letter and personnel record (LIC501). C1's appraisal needs and services plan, identification and emergency contact, functional capability, dangerous propensities, Interpersonal program plan (IPP).

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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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