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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200823
Report Date: 07/02/2024
Date Signed: 07/02/2024 12:16:19 PM

Document Has Been Signed on 07/02/2024 12:16 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 CARE IIFACILITY NUMBER:
079200823
ADMINISTRATOR/
DIRECTOR:		MARIA A GILFACILITY TYPE:
735
ADDRESS:2933 EL PASO WAYTELEPHONE:
(925) 978-4890
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 6DATE:
07/02/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Olivia Gonzalez, Direct Support StaffTIME VISIT/
INSPECTION COMPLETED:
12:25 PM
NARRATIVE
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On 7/2/2024 at 11:10am, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Olivia Gonzalez, Direct Support Professional. LPA spoke with Administrator, Maria Gil, via telephone and was advised she is out-of-the country.

While LPA L. Hall was conducting a complaint investigation 15-AS-20240701091410 on 7/2/2024. Upon arrival LPA observed that S2 was not associated to facility. LPA also was not notified that Administrator would be out-of-the country, and there was not a backup Administrator to meet qualifications.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report, appeal rights, and LIC421BG provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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 2
Document Has Been Signed on 07/02/2024 12:16 PM - It Cannot Be Edited


Created By: Laura Hall On 07/02/2024 at 11:36 AM
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: J & M RESIDENTIAL CARE II
FACILITY NUMBER: 079200823

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2024
Section Cited
CCR
80019(e)(3)

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80019 Criminal Record Clearance (e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility: (3) Request a transfer of a criminal record clearance...
This requirement was not met as evidence by:
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Administrator agreed to have S2 associated and advise CCLD that it was completed.
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Based on record review the Licensee did not comply with the section cited above in having S2 associated to facility prior to working, which poses a potential health and safety risk to persons in care.
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Type B
07/09/2024
Section Cited
CCR85064(f)

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85064 Administrator Qualifications and Duties (f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications... who shall be capable of, and responsible and accountable for, management and administration of the facility... This requirement was not met as evidence by:
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Administrator agreed to assign a backup while absent and submit information to CCLD by POC date.
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Based on observation the Licensee did not comply with the section cited above by having a backup administrator while absent, which poses a potential health and safety risk to persons in care.
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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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024


LIC809 (FAS) - (06/04)
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