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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200970
Report Date: 04/25/2023
Date Signed: 04/25/2023 03:08:33 PM


Document Has Been Signed on 04/25/2023 03:08 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:
04/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Joy Bisaha, Administrator TIME COMPLETED:
03:30 PM
NARRATIVE
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On 4/25/2023 at 12:45PM Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct an annual required inspection. LPA met with Administrator Joy Bisaha. Facility has census of 0. During facility inspection, LPA observed zero (0) clients. At 2:20PM, licensee Renee Tang arrived at the facility.

LPA toured facility with Administrator including but not limited to the client’s bedroom, common areas, kitchen, and outdoor area. Clients’ bedrooms are equipped with the proper furniture and bedding linens. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. The kitchen was observed cleaned and within compliance. Living room is equipped with the proper furniture for the clients. There is a designated storage cabinets for cleaning supplies and knives. Indoor and outdoor passageways were free of obstruction. Fire extinguishers was observed at the facility located at the living room area, however, the service tagged stated that last serviced was April 22,2022.

Smoke detectors and sprinklers are interconnected. Carbon monoxide detector was observed to be in working condition. Medication cabinet has a lock. LPA advised Licensee and Administrator that hot water temperature should be maintained between 105 degrees F and 120 degrees F. Freezer temperature was observed at 0 degrees Fahrenheit. Refrigerator temperature measured at 40 degrees Fahrenheit.

Facility has supplies of PPEs, paper supplies and hygiene supplies. Facility has a mitigation plan and infection control plan.

...Continue to LIC809C...
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
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 4


Document Has Been Signed on 04/25/2023 03:08 PM - It Cannot Be Edited

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: 079200970

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

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 licensee failed to obtain facility's liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/05/2023
Plan of Correction
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Administrator stated she will let licensee know to obtain liability insurance, a copy of liability insurance by POC date needs to be submitted to CCL office.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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. LPA observed fire extinguisher was last serviced on April 22,2022 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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By POC date Licensee will have fire extinguisher serviced or replaced, and submit a copy of tag to CCL by fax or email.
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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/25/2023 03:08 PM - It Cannot Be Edited

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: 079200970

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)
Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical….(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained…

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 licensee failed to maintain current first aid kit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Administrator stated that she will buy a new first aid kit. A receipt and picture of the new first aid kit will need to be submitted to CCL 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: 079200970
VISIT DATE: 04/25/2023
NARRATIVE
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LPA observed the following:

1. At around 2:00pm LPA observed that, licensee failed to maintain current first aid kit

2. At around 1:30PM LPA observed that fire extinguisher’s service date was April 22,2022

3. At around 2:10pm, LPA observed that, Licensee failed to obtain liability insurance

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 was conducted with Administrator and Appeal Rights was provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4