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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200866
Report Date: 05/04/2024
Date Signed: 05/04/2024 04:35:01 PM

Document Has Been Signed on 05/04/2024 04:35 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/
DIRECTOR:		SAN MATEO, JOSEFINA AFACILITY TYPE:
735
ADDRESS:4667 GREENBUSH DRIVETELEPHONE:
(925) 429-1690
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 6CENSUS: 4DATE:
05/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Ramon Sarimento, Direct Care SupportTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 5/4/2024 at 9:35am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced annual 1-year required inspection. LPA met with Ramon Sarimento, Direct Care Support, and explained the purpose of the visit. Administrator, Josefina San Mateo, arrived at 3:20pm. The administrator currently holds a certificate (#6017802735) that expires on 05/10/2025. The facility’s fire clearance was approved for six (6) ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of five (5) bedrooms and two (2 ) bathrooms. One (1) bedroom occupied by staff. All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 70 degrees 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 108.8 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Continued on LIC809C
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2024
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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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: 05/04/2024
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Continued from LIC809.

Smoke detectors/carbon monoxide were in operating condition during visit. Emergency disaster plan last updated on 4/1/2024. Fire extinguisher was last services on 11/15/2024. Fire drill last conducted 3/15/2024. First aid kit was observed to be complete.

Four (4) staff records were reviewed and complete. All four (4) clients' records reviewed, current, and complete. LPA reviewed P & I and a sample of medication.

The following forms to be updated and submitted to CCLD by 5/13/2024:
  • Surety Bond
  • LIC500 (Personnel Record)
  • LIC308 (Designation of facility Responsibility)
  • LIC 400 Affidavit Regarding Client/Resident Cash Resources
  • Updated facility sketch showing activity room.


No deficiencies cited during visit

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

DATE: 05/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2024
LIC809 (FAS) - (06/04)
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