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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701114
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:58:10 PM

Document Has Been Signed on 11/02/2023 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
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:
11/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Christine QuiruzTIME COMPLETED:
02:00 PM
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On 11/2/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Christine Quiruz and explained the purpose of the visit. There was one other staff member was present at this time, Reginald Sanpablo.

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 3. 3 out 3 residents were out their respective day program.
LPA reviewed 6 staff files and 3 residents files. All of which were current and up to date. The administrator has a current administrator certificate #6022150735 and expires on 11/06/2024.
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 03/19/2023.
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 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: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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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: 11/02/2023
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Laundry room was identified. Laundry detergent was locked and made inaccessible. 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.

The following forms and documents were requested to be updated and submitted into CCL.
-LIC 308
-LIC 400
-LIC 500
-LIC 610e

No deficiencies were observed or cited during this annual visit. An exit interview was conducted and a copy of this report was provided at the end of this visit.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC809 (FAS) - (06/04)
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