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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 11:44:30 AM

Document Has Been Signed on 10/13/2021 11:44 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Meljo Chu, ApplicantTIME COMPLETED:
12:00 PM
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On 10/13/21 at 11:30AM while conducting a pre-licensing inspection at the facility, a component III presentation was also completed with applicant.

LPA discussed Title 22 regulations with applicant with most common deficiencies cited at adult care facilities and how to mitigate/avoid them.

The applicant was reminded of the statute that requires CCLD to be notified within 5 business days of admitting their first client. This notification may be done by phone, mail or fax.

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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