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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200970
Report Date: 05/15/2024
Date Signed: 05/15/2024 04:36:29 PM

Document Has Been Signed on 05/15/2024 04:36 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:
079200970
ADMINISTRATOR/
DIRECTOR:		BISAHA, JOYFACILITY TYPE:
740
ADDRESS:1206 DAINTY AVETELEPHONE:
(925) 895-0756
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 10CENSUS: 2DATE:
05/15/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Licensee, Renee TangTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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On 5/15/2024 at 2:30 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of The Department receiving notification from Contra Costa Fire Department that the facilities fire clearance has been temporarily suspended. LPA met with Licensee, Renee Tang and explained the purpose of the visit.

LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. LPA obtained copies of the resident roster and emergency ID's. Two residents were observed at the facility. The residents are to be relocated by the end of day. Licensee has provided the names and addresses of where the residents are being relocated. Licensee will not admit any more residents until all fire clearance requirements are met and a new fire clearance is obtained. Licensee is to notify CCLD once residents are relocated.

THE FOLLOWING DEFICIENCIES ARE BEING CITED:
  • Licensee admitted residents prior to clearing fire code violations

  • Licensee failed to maintain their fire clearance





The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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 05/15/2024 04:36 PM - It Cannot Be Edited


Created By: Alona Gomez On 05/15/2024 at 03:47 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: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2024
Section Cited
CCR
87764(a)(1)

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(a) The Department may order a suspension... following circumstances:(1) When a facility is cited for a deficiency that presents a direct and immediate risk ...licensee fails to correct the deficiency immediately.

This requirement is not met as evidenced by:
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By POC date Licencee agrees to relocate residents and notify CCLD imediatley
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Based on observation and report from local fire department the facility admitted residents with unleared fire codes which poses an imediate health and safety risk to persons in care.
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Type A
05/29/2024
Section Cited
CCR87202(a)

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(a) All facilities shall maintain a fire clearance ... Prior to accepting ...providing fire protection services, or the State Fire Marshal.


This requirement is not met as evidenced by:
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Based on observation and report from local fire department the facility does not have a valid fire clearence
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By POC date Licensee agrees to be in regulation with fire clearence requirements and notify CCLD
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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