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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201115
Report Date: 01/10/2023
Date Signed: 01/10/2023 01:14:32 PM

Document Has Been Signed on 01/10/2023 01:14 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: 2DATE:
01/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Emily Carbonell, StaffTIME COMPLETED:
12:20 PM
NARRATIVE
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On 01/10/2023 at 12:00PM Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an incident reports received for Client 1 (C1). LPA met with Emily Carbonell, Staff and explained the purpose of the visit. Caregiver, Melva Reyes, arrived at 12:30PM. Administrator, Elvie Chu, arrived at 12:40PM

Upon arrival LPAs was greeted by Staff 2 (S2) whom was not associated to the facility.

Incident report sent on 12/31/2022 was for an AWOL for C1. Staff 1 (S1) stated that C1 left without notifiying any staff and stayed the night at a friend's house. C1 does not have a cell phone. S1 stated staff called friend and found that's where she was at the time. C1 returned the next day 1/1/2023.

LPAs collected the following documents during visit: C1's Individual Program Plan (IPP) addendum, and appraisal needs and services plan.

LPA requested the following documents be submitted by 1/13/2023: LIC500 Personnel Record and facility roster.

Continued on LIC809C.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2023
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: 01/10/2023
NARRATIVE
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Continued from LIC809.

LPAs observed the following deficiency.

-At 12:05PM, LPA observed S2 was not associated to the facility.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/10/2023 01:14 PM - It Cannot Be Edited


Created By: Laura Hall On 01/10/2023 at 12:21 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: 01/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/11/2023
Section Cited
CCR
80019(e)(1)

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80019 (e) All individuals subject to a criminal record review... shall prior to working...in a licensed facility:(1) Obtain a California clearance... as required by the Department or This requirement was not met as evidence by:
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Administrator agreed to submit an LIC9182 and a copy of S2's identification or add S2 to guardian and submit proof to CCLD by POC date.
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Based on LPA's observation the Licensee did not comply with the section cited above in having S2 associated to the facility, which poses a potential health and safety risk to persons in care.
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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: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2023


LIC809 (FAS) - (06/04)
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