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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200965
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:31:10 AM

Document Has Been Signed on 10/31/2022 11:31 AM - 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 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: 2DATE:
10/31/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Joy Bisaha, Staff
Jon Gonzales, Caregiver		TIME COMPLETED:
11:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/31/2022 at 10:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a health and safety check as a result of a priority 2 complaint. LPA met with caregiver, Jon Gonzales and informed him reason for visit. Staff, Joy Bisaha and Administrator, Renee Tang arrived 20 minutes later.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 119 degrees F in the hallway bathroom sink. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Client's medications were kept locked in the file cabinet. Smoke and Carbon monoxide detectors observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 4/22/2022. There are no accessible bodies of water observed.

At 9:40AM, LPA observed unlocked laundry detergent in the client's bedroom. Caregiver locked up laundry detergent during inspection.

At 11:00AM, LPA was informed there was no physician's report for one of the clients prior to admission.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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 10/31/2022 11:31 AM - It Cannot Be Edited


Created By: Grace Luk On 10/31/2022 at 10:14 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 AND R HOME CARE LLC
FACILITY NUMBER: 079200965

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2022
Section Cited
CCR
80087(g)

1
2
3
4
5
6
7
Buildings and Grounds. Disinfectants, cleaning solutions, ...and other items that could pose a danger...shall be stored where inaccessible to clients. This requirement is not met as evidence by:
1
2
3
4
5
6
7
Caregiver locked up the laundry detergent during inspection.


Deficiency cleared.
8
9
10
11
12
13
14
Based on observation, licensee did not comply with the section cited above by having unlocked laundry detergent which poses an immediate health and safety risk to the persons in care.
8
9
10
11
12
13
14
Type B
11/14/2022
Section Cited
CCR80069(b)

1
2
3
4
5
6
7
Client Medical Assessment. In ARFs , prior to accepting a client into care, the licensee shall obtain ...the client's medical assessment. This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator has agreed to obtain a copy of the client's physician's report and submit a copy to CCLD by POC date.
8
9
10
11
12
13
14
Based on interview, licensee did not comply with the section cited above by not having client's physician's report which poses a potential health and safety risk to the persons 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.
SUPERVISOR'S NAME:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2