<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200965
Report Date: 02/18/2022
Date Signed: 02/18/2022 04:24:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/14/2022 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20220214091428
FACILITY NAME:J AND R HOME CARE LLCFACILITY NUMBER:
079200965
ADMINISTRATOR:TANG, RENEEFACILITY TYPE:
735
ADDRESS:773 SARAH STREETTELEPHONE:
(925) 895-0756
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:5CENSUS: 3DATE:
02/18/2022
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Joy Bisaha, staff TIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not following COVID-19 guidelines during admission
Did not obtain admission document prior to admitting clients
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 02/18/2022 at 2:15 PM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to in order to meet the 10-day requirement for the above allegations. LPA met with S2, staff on duty, LPA called Administrator Renee Tang, Administrator is not available during the visit, at around 2:50PM, staff Joy Bisaha arrived at the facility. LPA explained the purpose of the visit with Joy B.

LPA toured the facility with S2. LPA conducted interview and records review. LPA observed that there are no admission agreements, Covid19 test results prior to admission & physician’s assessment for C2 & C3.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20220214091428
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: J AND R HOME CARE LLC
FACILITY NUMBER: 079200965
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2022
Section Cited
CCR
80069(b)
1
2
3
4
5
6
7
80069 Client Medical Assessment
(b) In ARFs , prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Facility staff agreed to complete C2 & C3'S clinical assessment document, proof of documentation need to be submitted to CCL office by POC date.
8
9
10
11
12
13
14
Based on the observation and interview, the licensee failed to ensure to obtain clients medical assessment prior to admission, which poses a potential health and safety risks to clients in care.
8
9
10
11
12
13
14
Type B
02/25/2022
Section Cited
CCR
80068(a)
1
2
3
4
5
6
7
80068 Admission Agreements
a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not me as evidence by:
1
2
3
4
5
6
7
Facility staff agreed to complete C2 & C3'S admission agreement document, proof of documentation need to be submitted to CCL office by POC date.
8
9
10
11
12
13
14
Based on the observation and interview, the licensee failed to ensure to complete a written admission agreement for C2 & C3, which poses a potential health and safety risks to clients in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20220214091428
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: J AND R HOME CARE LLC
FACILITY NUMBER: 079200965
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/25/2022
Section Cited
CCR
80072(a)(2)
1
2
3
4
5
6
7
80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2)To be accorded safe...

This requirement is not met as evidence by:
1
2
3
4
5
6
7
All staff including Adminsitrator will need to get training about covid19 guidelines, including but not limited to PIN 21-17.1 ASC. Staff name and signature need to be submitted to CCL office by POC date.
8
9
10
11
12
13
14
Based on the observation and interview, the licensee failed to ensure to obtain covid19 test prior to admission which poses a potential health and safety risks to clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5