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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201098
Report Date: 12/16/2022
Date Signed: 12/16/2022 10:32:29 AM

Document Has Been Signed on 12/16/2022 10:32 AM - 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 DRTELEPHONE:
(908) 420-8480
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 6DATE:
12/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elvie Chu, CaregiverTIME COMPLETED:
10:35 AM
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On 12/16/2022 at 09:30PM, Licensing Program Analysts (LPAs) L. Hall and C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPAs spoke with Administrator Joy Chu via telephone and explained the reason for the visit. Caregiver, Elvie Chu, arrived at 09:55AM.

Upon entry, LPA's temperature was checked. LPA observed COVID-19 signs were posted on the front door. Facility uses back entrance as main entrance and that is where the screening station is located. LPAs toured facility including but not limited to common areas, bathrooms, bedrooms, back yard, kitchen, and garage. LPAs observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 112.7 degrees Fahrenheit. Fire extinguisher last serviced on 09/30/2022. There is a minimum of 7-day non-perishables and 2-day perishables foods.

During record review, LPA observed visitors sign-in log. LPA observed facility has a copy of the Infection Control Plan on file. LPA observed PPE and paper supplies are sufficient.

No deficiencies cited during visit.

Exit interview and a copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
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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