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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201115
Report Date: 10/13/2021
Date Signed: 10/13/2021 11:42:55 AM

Document Has Been Signed on 10/13/2021 11:42 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 HOME, CORP.FACILITY NUMBER:
079201115
ADMINISTRATOR:CHU, MELJO LISEFACILITY TYPE:
735
ADDRESS:3212 VIEW DRIVETELEPHONE:
(408) 420-8480
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 0DATE:
10/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Meljo Chu, ApplicantTIME COMPLETED:
11:00 AM
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On 10/13/2021 at 10AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an announced pre-licensing inspection and met with applicant. LPA explained the purpose of the visit with applicant.

LPA along with the applicant toured the facility inside and out including but not limited to the bedrooms, bathrooms, common living areas, kitchen, garage and backyard. The facility has a total of four (4) bedrooms and two (2) bathrooms. There is sufficient lighting around the facility. Clients rooms are equipped with the proper furniture, bedding, and lighting. Bathrooms showers/tubs were equipped with grab bars and non- skid mats. Trash bins with foot operated lids were observed in the bathrooms and kitchen areas.

Passageways and hallways are free of obstruction and fire hazards. LPA observed a locked kitchen cabinet that will store medications. Thermostat in hallway showed temperature at 69 degrees Fahrenheit. Hot water temperature is measured at 109 degrees Fahrenheit. Fire extinguisher was last serviced on 09/27/2020. There is a minimum of 7-day non-perishables and 2-day perishables foods. Carbon monoxide and smoke detectors were in working condition.

Facility is ready to be licensed and no deficiencies were observed during visit. LPA advised applicant final review and approval of license will be done by the Central Applications Unit (CAU) in Sacramento CA. Additional requirements may need to be provided. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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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