079200965-3-27-2023-15-AS-LIBO-CQBTVR-20230327150422

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200965
Report Date: 03/27/2023
Date Signed: 03/27/2023 03:04:45 PM

Document Has Been Signed on 03/27/2023 03:04 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 LLC		FACILITY NUMBER:	079200965
ADMINISTRATOR:	TANG, RENEE		FACILITY TYPE:	735
ADDRESS:	773 SARAH STREET		TELEPHONE:	(925) 895-0756
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY: 5		CENSUS: 2	DATE:	03/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Joy Bisaha, staff		TIME COMPLETED:	03:25 PM

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 this day 03/27/2023 at around 12:15PM, Licensing Program Analyst (LPA) L. Ibo arrived at the facility to conduct annual required inspection. LPA was met by caregiver S3. Administrator Renee Tang was called to inform her the purpose of the visit, according to Administrator she is not available to meet with LPA since she is at her other facility. At around 1:05PM, staff Joy Bisaha arrived at the facility. LPA inspected the facility inside and out including but not limited to bedrooms, bathrooms, kitchen, garage dining and living areas. The facility has 4 bedrooms and 2 bathrooms. One bedroom is designated as staff room/office room and 1 bathroom is dedicated for staff room. There are 2 clients observed. Facility has an approved fire clearance for 6 ambulatory clients. One fire extinguisher was observed by the dining room adjacent to kitchen, date of service was April 2022. Facility has sufficient supply of perishable and non-perishable foods. There are 1 staff working during the visit and both are fingerprint cleared. Bathroom were observed with grab bars and nonskid mats. LPA reviewed 2 clients and 2 staff files and interviewed 2 clients and 2 staff. Facility has wired carbon monoxide and smoke detector that were observed functional. ...Continue to LIC809-C...

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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 6

Document Has Been Signed on 03/27/2023 03:04 PM - It Cannot Be Edited

Created By: Leslie Ibo On 03/27/2023 at 02:25 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation , the licensee did not comply with the section cited above in licensee failed to maintain hot water temperature between 105-120 degrees F, LPA observed at 124.7F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2023
	Plan of Correction
1 2 3 4	Corrected during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 6

Document Has Been Signed on 03/27/2023 03:04 PM - It Cannot Be Edited

Created By: Leslie Ibo On 03/27/2023 at 02:25 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80088(a)(1)

Fixtures, Furniture, Equipment, and Supplies

(1) The licensee shall maintain the temperature in rooms that clients occupy between a minimum of 68 degrees F (20 degrees C) and a maximum of 85 degrees F (30 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in licensee failed to maintain facility temperature between 68F-85F, LPA observed that temperature was set at 67F which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2023
	Plan of Correction
1 2 3 4	Corrected during the visit.

Type B

Section Cited

CCR

80088(b)

Fixtures, Furniture, Equipment, and Supplies

(b) All window screens shall be in good repair and be free of insects, dirt and other debris. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in licensee failed to maintain screen doors/windows in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2023
	Plan of Correction
1 2 3 4	Staff stated that they will replace or repair both clients screen door/windows. LPA requested a proof of correction to be submitted by POC 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: 03/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

Page: 3 of 6

Document Has Been Signed on 03/27/2023 03:04 PM - It Cannot Be Edited

Created By: Leslie Ibo On 03/27/2023 at 02:25 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85064(e)

Administrator Qualifications and Duties

(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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in Administrator admitted that she was not present at the facility with the required number of hours, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Administrator agrees to submit updated LIC 500 showing administrative hours where an administrator is available during business hours to CCLD by POC date and self-certification that Administrator will abide with the number of hours written on the LIC500.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 03/27/2023 03:04 PM - It Cannot Be Edited

Created By: Leslie Ibo On 03/27/2023 at 02:25 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(b)(6)(D)(2)

Health-Related Services

(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information: (2) The exact dosage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review , the licensee did not comply with the section cited above in one medication (vitamin D3) for C2 has a lower dosage from the doctors order which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/28/2023
	Plan of Correction
1 2 3 4	Staff will buy an over the counter medication VItamin D3 that will match on the doctor's order. Staff will send proof of correction by POC 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: 03/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: 03/27/2023

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
26
27
28
29
30
31
32

LPA observed the following:
At 1:42PM, LPA observed that bathroom hot water temperature was measured at 124.7F.
At 12:45PM, LPA observed that facility temperature was set-up at 67F.
At 12:40PM, LPA observed that client’s door screen was not in good repair.
At around 1:00PM, based on interview with Administrator, she admitted that she was not present at the facility with sufficient number of hours and records review revealed she was scheduled at the facility for only Wednesday and Friday from 10am-2:00pm.
At 1:50PM, LPA observed staff was giving lower dosage of C2’s medication (Vitamin D3), doctor’s order was 25mcg and staff was providing 10mcg.

Deficiencies are being cited today in violation of California Code of Regulations and follows on 809D. Failure to submit proof of corrections (POC's) along with LIC9098 by plan of correction due dates may result in civil penalty.

Exit interview was conducted with Administrator and Appeal Rights was provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC809 (FAS) - (06/04)

Page: 6 of 6