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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201098
Report Date: 11/16/2021
Date Signed: 11/16/2021 05:02:27 PM

Document Has Been Signed on 11/16/2021 05:02 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:JRCE RESIDENTIAL HOMEFACILITY NUMBER:
079201098
ADMINISTRATOR:CHU, MELJO LISEFACILITY TYPE:
735
ADDRESS:4208 NULL DR.TELEPHONE:
(908) 420-8480
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 6DATE:
11/16/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:MELJO CHUTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) James Sampair conducted an unannounced pre-licensing inspection and met with Licensee and Administrator, Meljo "Joy" Chu. LPA explained the reason for the visit. LPA observed all staff wearing masks when clients were present. LPA also observed staff interacting with residents appropriately during the visit.

LPA toured the facility inside and outside including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, garage, and the backyard. The facility has sufficient lighting. The residents' rooms included appropriate furniture, lighting, bedding, and linens. The bathrooms were equipped with nonskid mats and hygiene items. The living room was equipped with the proper furniture, and all toxins or sharp objects were kept safely in locked cabinets.

Passageways and hallways were free of obstruction. Fire extinguisher is fully charged and last checked in September of 2021. Smoke and Carbon Monoxide detectors were operational. Medication cabinet was locked and first aid kit was complete. Hot water temperature was measured at 120 degrees F. Sufficient 2 day perishable and 7 days of non-perishable food supplies were observed in the storage cabinets, refrigerators, and freezers. Emergency supplies were adequate. Complaint poster, personal rights, Ombudsman and rights to council posters were observed.

However, there was exposed wiring in the back room addition and non-licensed contractor electrical work was being performed by 2 staff members in the living room. For those reasons, the facility is not ready to be licensed until the Applicant has sent proof to LPA that the exposed wiring has been protected and the work in the living room has been completed by a licensed electrician.

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SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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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: JRCE RESIDENTIAL HOME
FACILITY NUMBER: 079201098
VISIT DATE: 11/16/2021
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This facility is not yet licensed and is subject to final approval by CAU. Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
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