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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200970
Report Date: 04/20/2022
Date Signed: 04/20/2022 03:38:42 PM

Document Has Been Signed on 04/20/2022 03:38 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:
079200970
ADMINISTRATOR:BISAHA, JOYFACILITY TYPE:
740
ADDRESS:1206 DAINTY AVETELEPHONE:
(925) 895-0756
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 10CENSUS: 0DATE:
04/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joy Bisaha, AdministratorTIME COMPLETED:
04:10 PM
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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 Administrator Joy Bisaha. Facility do not have any residents during the visit. Administrator stated that facility will have “soft-opening” on June 2022.

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. Facility observed that facility is not ready to accept residents. LPA observed that residents’ rooms are unorganized, boxes of facility supplies stored in different residents rooms.

Infection control designated leader is Joy Bisaha. LPA observed COVID-19 signage posted in common areas to promote hand washing, cough/sneeze etiquette and physical distancing. Facility has a mitigation plan and maintains record of routine screening for residents and staff.

Facility has locked medication supply storage. Smoke and Carbon monoxide detectors were operational.
LPA asked Administrator to have 30 days supplies of PPEs. LPA also reminded to once she hire staff at the facility have the staff get N95 Fit testing.

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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2022 03:38 PM - It Cannot Be Edited


Created By: Leslie Ibo On 04/20/2022 at 03:21 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: 079200970

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPA observed all residents bedrooms are unorganized and fire extinguisher need to be replace or service which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2022
Plan of Correction
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Administrator agreed to organize the facility, all residents rooms and common areas, need to get a new fire extinguisher picture need to be submitted to LPA 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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