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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200965
Report Date: 04/20/2022
Date Signed: 04/20/2022 01:06:39 PM

Document Has Been Signed on 04/20/2022 01:06 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: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:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Joy Bisaha, staf,f and Vimal Chand assistant administratorTIME COMPLETED:
01:30 PM
NARRATIVE
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On 4/20/2022, Licensing Program Analyst (LPA) Leslie Ibo conducted an infection control annual inspection and explained the purpose of the visit with staff Joy Bisaha, at 11:00 AM LPA called Administrator Renee Tang to inform her the purpose of the visit, per Administrator she is not available and designated Joy Bisaha to receive copy of report. Assistant Administrator Vimal Chand arrived at the facility around 12:00PM. LPA observed 2 clients at the facility.

LPA inspected the facility inside and outside. No bodies of water observed during the visit. Pathways were observed to be free of obstruction and fire hazards.

Infection control designated leader is Vimal Chand. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. A thermometer and hand sanitizer were observed at screening station. Facility staff were observed to be wearing proper PPE (mask). Facility has a mitigation plan.

...Continue on LIC809C..
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
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 4
Document Has Been Signed on 04/20/2022 01:06 PM - It Cannot Be Edited


Created By: Leslie Ibo On 04/20/2022 at 12:30 PM
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: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85064(e)
(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in Administrator stated that the last time she was at the facility was two weeks ago which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Administrator shall provide an updated LIC 500 and submit paperwork for the new assigned Administrator (letter showing when they started, copy of administrator certification, LIC 501) to LPA by POC due date (4/22/2022).
Type B
Section Cited
CCR
80087(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatio & interview, the licensee did not comply with the section cited above in fire extinguisher last service date was February 2021,which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2022
Plan of Correction
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Licensee shall send LPA pictures of the receipt for the purchase of a new fire extinguisher or new service date.
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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022


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: J AND R HOME CARE LLC
FACILITY NUMBER: 079200965
VISIT DATE: 04/20/2022
NARRATIVE
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Medications are centrally stored in a locked area that is inaccessible to clients and refilled every at least 30 days. There was at least 7 days of nonperishable and 2 days of perishable foods. Water temperature was checked with 114 degrees Fahrenheit. Smoke and Carbon monoxide detectors were operational.

LPA interviewed Administrator and she stated that the last time she visited the facility was about two weeks ago, LPA reminded Administrator Renee Tang that a certain number of hours is necessary to manage and administer the facility in compliance. There is no proof or documentation sent to CCL office stating Vimal Chand is a backup administrator.

The following are observed during the visit:

1. N95 fit testing needed for all staff
2. Infection control training for all staff (see lic9099d)
3. Documentation for covid19 screening for all staff, residents and visitors is needed
4. Facility need 30 days’ supply of PPE’s
5. Facility need new fire extinguisher, LPA reminded Assistant Administrator that fire extinguishers/s need to be service annually.

Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties.

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

DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/20/2022 01:06 PM - It Cannot Be Edited


Created By: Leslie Ibo On 04/20/2022 at 12:33 PM
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: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(f)(5)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. (5) Recognition of early signs of illness and the need for professional assistance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview & record review, the licensee did not comply with the section cited above in proof of infection control training for staff was not observed during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2022
Plan of Correction
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Assistant administrator Vimal Chand stated that he will send a copy of proof of infection control training to LPA L.Ibo by POC date.
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:Leslie Ibo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022


LIC809 (FAS) - (06/04)
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