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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701114
Report Date: 11/12/2021
Date Signed: 11/12/2021 11:28:46 AM

Document Has Been Signed on 11/12/2021 11:28 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:JEN'S PLACE ARFFACILITY NUMBER:
392701114
ADMINISTRATOR:QUIREZ, CHRISTINEFACILITY TYPE:
735
ADDRESS:1777 BUTTERCUP LANETELEPHONE:
(209) 914-2882
CITY:TRACYSTATE: CAZIP CODE:
95378
CAPACITY: 4CENSUS: 0DATE:
11/12/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Christine Quirez, LicenseeTIME COMPLETED:
11:31 AM
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Licensing Program Analyst (LPA) Arlene Garcia arrived announced to conduct a Pre-licensing visit on 11/12/21 and met with Christine Quirez, Licensee.
The facility will be licensed for a capacity of 6 non-ambulatory residents.

Licensee has facility in Manteca Jens Place Facility #392700586 where they will be moving clients to this new location once license is approved. Licensee has two bedrooms to show the set up and will move the remaining required furniture once license has been approved. Clients are currently using the furniture at the other location.
LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA did not observe residents during this visit.
Although there were no residents, LPA observed 2-day perishables and 7-day non-perishables.
The temperature inside the facility was observed to be at 69 *F which is within the required range of 68-85*F. The hot water temperature was measured at 117.7*F which is within the required range of 105-120*F.
LPA observed fire extinguisher(s) 5/4/2021,, smoke and carbon monoxide detectors, and central heating and air in the facility.
LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide.
Component III conducted- Licensure pending.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arlene D Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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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