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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701114
Report Date: 11/07/2022
Date Signed: 11/08/2022 02:41:32 PM

Document Has Been Signed on 11/08/2022 02:41 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, 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: 3DATE:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Christine QuiruzTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Arielle Pascua conducted an unannounced post licensing visit on 09/07/2022. LPA Pascua was met with Facility Designated Administrator, Christine Quiruz., and explained the purpose of the visit. The purpose of this visit is to conduct a post-licensing visit.
This facility is licensed to served and accept up to 4 residents who are deemed to be ambulatory only. This facility is also vendorized to accept and retain Level 4I residents at this time. Census was currently at 3.
The facility has a main entrance screening point. The facility has Covid-19 posting throughout the facility. The facility has a 30 day supply of PPE. The facility conducts disinfecting cleaning daily.
Tour of the facility was conducted.
The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Armor Fire Extinguisher Company 05/19/2022.
The kitchen area was toured. LPA observed a sufficient seven days of non-perishable foods as well as two days worth of perishable food supplies in the main kitchen. Additional non-perishable food was identified in the additional pantry in the hallway. Additional perishable food was identified in the additional freezer in the garage.
Dining areas, living areas, and all other areas intended for resident use were toured. It was observed that furniture and furnishings were sufficient and able to meet the needs of the residents at this time.
A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees.
A tour of the resident bedrooms was conducted. Resident furniture was observed to be sufficient to meet the resident needs at this time.
LPA Pascua observed a locked centralized stored medication located in the hallway. Along with Administrator, the LPA observed, reviewed, and compared resident medication with the medication dispensing logs. First Aid Kit was present and contained all of the required components.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2022
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 2
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: JEN'S PLACE ARF
FACILITY NUMBER: 392701114
VISIT DATE: 11/07/2022
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The exterior of the physical plant was in good repair with no hazards present. Perimeter fence was observed to be stable and gates were in good repair.

No deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of this report was given to Facility Designated Administrator.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
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