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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201115
Report Date: 09/28/2022
Date Signed: 09/28/2022 01:55:52 PM

Document Has Been Signed on 09/28/2022 01:55 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 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:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Melva Reyes, CaregiverTIME COMPLETED:
02:00 PM
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On 9/28/2022 at 12:30PM, Licensing Program Analysts (LPAs) L. Hall and L. Alexander arrived unannounced to conduct an Infection Control Inspection. LPA spoke with Administrator Joy Chu via telephone and explained the reason for the visit. Caregiver, Melva Reyes, arrived at 1:02PM. Facility is not in operation, no clients present.

Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs were posted. LPA toured facility including but not limited to common areas, bathrooms stations, bedrooms, kitchen, garage and backyard. All hand washing stations were equipped with soap and paper towel. Facility will place COVID signs before first client. Hot water temperature in the shared clients’ bathroom was measured at 96.4 degrees Fahrenheit. Fire extinguisher last serviced on 5/27/2022.

During record review, LPA observed visitors log and temperature log for both clients and staff. LPA observed facility has a copy of Infection Control Plan on file. LPA observed paper supplies are sufficient.

No deficiencies cited during this visit.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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