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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002947
Report Date: 11/08/2023
Date Signed: 11/08/2023 03:58:22 PM


Document Has Been Signed on 11/08/2023 03:58 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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: 5DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Administrator- Rasha Salman TIME COMPLETED:
04:15 PM
NARRATIVE
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On 11/08/2023, Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Bethany Mirlohi arrived unannounced at the facility to conduct a Required 1- year annual inspection utilizing the care tool. LPAs met with Administrator Rasha Salman.

LPAs and Caregiver conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: four private residents room, two bathrooms, kitchen, backyard, laundry room, and the common areas. LPAs observed all residents in their private bedrooms. LPAs observed the facility to have 2+ days of perishable and 7+ days of nonperishable foods. Water temperature was measured at 109 degrees.

LPAs observed cleaning spray to be store in the bathroom. LPAs informed administrator that cleaning spray needs to be locked away.

LPAs conducted a file review of one personnel and three residents records.

LPAs completed the full care tool and deficiencies was observed. Please see LIC 809-D.

Exit interview conducted and a copy of the report and appeal rights was provided.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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 11


Document Has Been Signed on 11/08/2023 03:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: J & H CARE HOMES
FACILITY NUMBER: 345002947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 objects which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2023
Plan of Correction
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Administrator to send a plan to LPA on how they are going to lock cleaning supplies. POC to be sent to LPA by of day, 5pm, on 11/09/2023
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 11


Document Has Been Signed on 11/08/2023 03:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: J & H CARE HOMES
FACILITY NUMBER: 345002947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not complete an infection control plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Administrator to send in complete infection control plan by 11/22/2023.
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 4 rooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Administrator to send in a plan on how residents rooms will be free from odor. Plans to be sent by 11/22/2023
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 11


Document Has Been Signed on 11/08/2023 03:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: J & H CARE HOMES
FACILITY NUMBER: 345002947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87613(a)(2)
87613General Requirements for Restricted Health Conditions
(a) Prior to admission of a resident with a restricted health condition, the licensee shall:
(2) Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2023
Plan of Correction
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Administrator to provide training to all staff providing care concerning Resident restricted health care conditions.
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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Cheyenne RatajczakTELEPHONE: (916) 969-7879
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
Page: 11 of 11