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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200965
Report Date: 03/20/2025
Date Signed: 03/20/2025 04:10:59 PM

Document Has Been Signed on 03/20/2025 04:10 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:J AND R HOME CARE LLCFACILITY NUMBER:
079200965
ADMINISTRATOR/
DIRECTOR:		TANG, RENEEFACILITY TYPE:
735
ADDRESS:773 SARAH STREETTELEPHONE:
(925) 634-8863
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 5TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Eliza Capio, Caregiver TIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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On 03/20/2024 at 1:35PM, Licensing Program Analyst (LPA) T. Syess-Gibson conducted an unannounced annual 1-Year required inspection. LPA met with Eliza Capio, Caregiver and explained the purpose of the visit. House Manager, Joy Bisaha arrived at 2:10 PM. The facility’s fire clearance was approved for one (1) ambulatory and four (4) non ambulatory clients.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard no bodies of water present. The facility consists of four (4) total bedrooms and two (2) bathrooms. One (1) bedroom used by staff. All indoor passageways are kept free of obstruction. A comfortable temperature for clients is maintained at 68 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 125.5 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. 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 non-perishables and 2-day perishables foods.

Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 06/03/2024 Fire drill last conducted 02/03/2025. Emergency Disaster Plan was last posted on 03/22/2024. First aid kit was observed to be complete.

Continued on LIC809C.

Harpreet HumpalTELEPHONE: (510) 285-3928
Tonica Syess-GibsonTELEPHONE: (510) 414-0641
DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: J AND R HOME CARE LLC
FACILITY NUMBER: 079200965
VISIT DATE: 03/20/2025
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Continued from LIC809

Three (3) staff records were reviewed, all staff have first aid certification. All three (3) clients' records reviewed, current, and complete.

The following forms to be updated and submitted to CCLD by: 03/27/2025.

· Liability insurance.


· LIC610D (Emergency and Disaster Plan for Adult Community Care Facilities and Residential Care Facilities for Chronically Ill)
· LIC308 (Designation of facility Responsibility)
· LIC 9020 (Register of Facility Clients/Residents)
· LIC 500 (Personnel Report)

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
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