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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700088
Report Date: 07/14/2021
Date Signed: 07/14/2021 05:22:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:NJ CARE HOMEFACILITY NUMBER:
342700088
ADMINISTRATOR:JAMES, MERLITAFACILITY TYPE:
740
ADDRESS:8200 WOODED BROOK DRIVETELEPHONE:
(916) 248-0652
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:6CENSUS: 4DATE:
07/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Merlita JamesTIME COMPLETED:
05:30 PM
NARRATIVE
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On 7/14/21 at 3:30pm Licensing Program Analysts (LPAs) Kevin Gould and Tirzah Hubbard arrived at NJ Care Home RCFE for the purpose of conducting a required 1 year annual inspection. LPAs met with Administrator, Merlita James and together conducted a tour of the home.

LPAs and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPAs observed the facility to be free of odor, clean and in good repair. LPAs observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 100 degrees F which meets does not meet the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. LPAs observed several freezers in the garage and kitchen with some items covered in freezer burn and without dates. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 610E Emergency Disaster Plan, Current Administrator Certificate and Client Roster.

Per California Code of Regulations, Title 22 the following deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NJ CARE HOME
FACILITY NUMBER: 342700088
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(28)
General Food Service Requirements
(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based LPAs review of food services and storage, the licensee did not comply with the section cited above as the garage freezer contained several food items that had been repackaged with no dates and freezer burn which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2021
Plan of Correction
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Administrator agreed to inventory both freezers (kitchen and garage) to ensure all food items stored without a date is discarded and any food with freezer burn is discarded. Licensee will submit written plan of correction with to ensure all food provided is of good quality and not expired.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NJ CARE HOME
FACILITY NUMBER: 342700088
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs testing of the hot water temperature the licensee did not comply with the section cited above as the hot water temperature recorded was 100 degrees which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2021
Plan of Correction
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LPAs observed the administrator turn up the hot water temperature. LPAs will conduct POC visit to ensure the water temperature meets regulations.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3