079201115-10-5-2023-15-AS-LHAL-CWC2HC-20231005172431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201115
Report Date: 10/05/2023
Date Signed: 10/05/2023 05:24:39 PM

Document Has Been Signed on 10/05/2023 05:24 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, ELVIE R		FACILITY TYPE:	735
ADDRESS:	3212 VIEW DRIVE		TELEPHONE:	(925) 238-0044
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94509
CAPACITY: 6		CENSUS: 3	DATE:	10/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Jose Buquel, Caregiver		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/5/2023 at 3:15pm, Licensing Program Analysts (LPAs) L. Hall and L. Alexander conducted an unannounced annual 1-year required inspection. LPAs met with Jose Buquel, Caregiver. Melva Reyes, Caregiver arrived at 3:40pm and LPAs explained the purpose of the visit. The facility’s fire clearance was approved for four (4) ambulatory and two (2) non-ambulatory clients. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area, garage, and back yard. The facility consists of four (4) total bedrooms and two (2 ) bathrooms. Two (2) bedroom is being used by staff All indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 77 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 96.1 degrees Fahrenheit. All toilets, hand washing, and bathing are safe, sanitary and in operating condition. Hand washing poster, paper towel, and soap observed at all hand washing stations. The supply of extra hygiene was available for residents. There is a minimum of 7-day non-perishables and 2-day perishables foods. Smoke detectors/carbon monoxide were in operating condition during visit. Fire extinguisher was last services on 6/5/2023. Fire drill last conducted 9/3/2023. First aid kit was observed to be complete. Continued on LIC809C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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, CORP.	FACILITY NUMBER: 079201115
	VISIT DATE: 10/05/2023

NARRATIVE

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Continued from LIC809.

Four (4) staff records were reviewed, One (1) of four (4) staff did not have health screening. All three (3) clients' records were reviewed, current, and complete. LPAs reviewed P & I.

LPA observed the following deficiencies:

At 4:50pm, LPA observed during record review S4 did not have health screening.

The following forms to be updated and submitted to CCLD by 10/12/2023:

LIC610D Emergency disaster plan (9 pages)
LIC500 (Personnel Record)
Client Roster
LIC308 (Designation of facility Responsibility)
Surety bond
LIC400 Affidavit Regarding Client/Resident Cash Resources

Exit interview conducted. A copy of the appeal rights and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/05/2023 05:24 PM - It Cannot Be Edited

Created By: Laura Hall On 10/05/2023 at 05:11 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JRCE RESIDENTIAL HOME, CORP.	FACILITY NUMBER: 079201115
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80066(a)(10)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in having S4 health screening which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Licensee will have S4 complete the health screening and submit signed copy to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Harpreet Humpal

LICENSING EVALUATOR NAME:

Laura Hall

LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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