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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002947
Report Date: 11/29/2022
Date Signed: 11/29/2022 11:16:00 AM


Document Has Been Signed on 11/29/2022 11:16 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926



FACILITY NAME:J & H CARE HOMESFACILITY NUMBER:
345002947
ADMINISTRATOR:SALMAN, RASHAFACILITY TYPE:
740
ADDRESS:8529 ARROWROOT CIRCLETELEPHONE:
(916) 905-8038
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 0DATE:
11/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Rasha Salman TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Talwinder Bains met with applicant, Rasha Salman , to conduct a
Pre- Licensing visit. LPA followed current Covid precautions- self screened, hand sanitized and surgical mask worn. The facility has a fire clearance for six (6) non-ambulatory residents. Applicant holds a current administrator certificate (# 6058898740 with expiration date 03/07/2023).

LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. Facility inspection is done for these areas but not limited to 6 bedrooms for residents, 1 staff room, 5 bathrooms, kitchen, common areas, garage, storage area ,outside area and laundry area . LPA observed facility to be properly furnished, including appropriate bedding and lighting in bedrooms. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 118 degrees F. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed at least a 2-day perishable and 7-day nonperishable food supply at the facility. LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detectors at the care home are operational. Fire extinguisher is ready for emergency use.

LPA completed the Pre-licensing inspection tool with applicant.

Pre-licensing passed and Component III was completed with applicant.

Applicant has satisfied all requirements in accordance to Title 22, California Code of Regulations. Application is pending and LPA will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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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