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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200866
Report Date: 05/24/2023
Date Signed: 05/24/2023 12:09:01 PM

Document Has Been Signed on 05/24/2023 12:09 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
E BAY DELTA AC/SC, 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:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Josefina San Mateo, AdministratorTIME COMPLETED:
12:15 PM
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On 5/24/2023 at 9:40 AM, Licensing Program Analyst (LPA) P. Watson arrived unannounced to conduct Required 1 Year Annual inspection. LPA met with Administrator, Josefina San Mateo and explained the purpose of the visit. The facility’s fire clearance was approved for 6 Ambulatory.

LPA toured the facility with Josefina, including but not limited to bedrooms, bathroom, kitchen, common area and backyard. The facility consists of 4 total bedrooms which 3 bedrooms are occupied by the clients and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 106.3 degree Fahrenheit. The toilet, hand washing station, and bathing station is safe, sanitary and in operating condition. LPA observed supply of extra hygiene items available for clients. There is a minimum of 7 day supply of non-perishables and 2 day perishables food supply.

Smoke detectors and carbon monoxide were in operating condition during visit. First aid kit was observed to be complete. Fire extinguisher was last serviced on 1/09/2023. Emergency Disaster Drill was last posted on 4/17/2023. Fire drill was last conducted on 4/15/2023.

Report continues on 809 C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE: DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: JIN'S HAVEN
FACILITY NUMBER: 079200866
VISIT DATE: 05/24/2023
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At 10:45 AM, LPA reviewed 4 of 4 residents records. At 10:30 AM, LPA reviewed 5 of 12 staff records and 5 of 5 have current first aid training and associated to the facility. At 11:40 AM, LPA reviewed a sample of 4 of 4 resident’s medications.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 6/14/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 610 D Emergency Disaster Plan


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Paris Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC809 (FAS) - (06/04)
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