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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200866
Report Date: 05/21/2022
Date Signed: 05/21/2022 12:03:43 PM

Document Has Been Signed on 05/21/2022 12:03 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:JIN'S HAVENFACILITY NUMBER:
079200866
ADMINISTRATOR:SAN MATEO, JOSEFINA AFACILITY TYPE:
735
ADDRESS:4667 GREENBUSH DRIVETELEPHONE:
(925) 429-1690
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 4DATE:
05/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Ramon Sarmiento, CaregiverTIME COMPLETED:
12:15 PM
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On 5/21//2022 at 10:25PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Ramon Sarmiento, Caregiver, and explained the purpose of the visit.

Upon entry, LPA's temperature was not checked. LPA did not observe screening or sign-in booklet for visitors. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing poster. Hot water temperature in the shared clients’ bathroom was measured at 104.3 degrees Fahrenheit. Fire extinguisher was last serviced on 2/14/2022

During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed food and paper supplies are sufficient.

The following forms are to be updated and submitted to CCLD by 5/27/2022:

-LIC500 Personnel Report
-LIC308 Designation of Administrative Responsibility

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2022
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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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: JIN'S HAVEN
FACILITY NUMBER: 079200866
VISIT DATE: 05/21/2022
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Continued from LIC809.

-LIC610E Emergency Disaster Plan
-An updated copy of Administrator certificate

The following deficiency were observed:

-At 3:15PM, LPA observed Staff 3 (S3) was not associated to the facility.

An immediate civil penalty of $300 was assessed.

The following deficiency were observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2022 12:03 PM - It Cannot Be Edited


Created By: Laura Hall On 05/21/2022 at 11:29 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: JIN'S HAVEN
FACILITY NUMBER: 079200866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)(1)
80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having S3 associated to facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2022
Plan of Correction
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Administrator agreed to submit LIC9182 and a copy of S3's identification to CCLD by POC date. Administrator submitted LIC9182 and idenficiation to LPA during visit. Deficiency cleared during visit.
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 Humpal
LICENSING EVALUATOR NAME:Laura Hall
LICENSING EVALUATOR SIGNATURE:
DATE: 05/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2022


LIC809 (FAS) - (06/04)
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