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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701114
Report Date: 12/06/2024
Date Signed: 12/07/2024 06:02:50 PM

Document Has Been Signed on 12/07/2024 06:02 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:JEN'S PLACE ARFFACILITY NUMBER:
392701114
ADMINISTRATOR/
DIRECTOR:		QUIREZ, CHRISTINEFACILITY TYPE:
735
ADDRESS:1777 BUTTERCUP LANETELEPHONE:
(209) 914-2882
CITY:TRACYSTATE: CAZIP CODE:
95378
CAPACITY: 4CENSUS: 3DATE:
12/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Christine Quiruz TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 12/06/2024, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct an annual visit. LPA met with Facility Designated Administrator (FDA), Christine Quiruz and explained the purpose of this visit.

This facility is vendorized by Valley Mountain Regional Center to be able to accept and retain up to (4) Level 4I residents at any given time.
This facility is licensed to serve up to (4) Ambulatory only residents at any given time.
Current census was 3. 3 out 3 residents were out of the facility at this time.
A brief interview with FDA Quiruz was conducted.
The facility administrator has an pending administrator certificate renewal. LPA was able to verify that this renewal was sent in prior to the past administrator certificate expiration date.
A review of 3 resident files and 3 staff files were conducted. Both staff and residents files were complete and up to date.

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 05/17/2024.
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.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JEN'S PLACE ARF
FACILITY NUMBER: 392701114
VISIT DATE: 12/06/2024
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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.

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: Lisa Rios
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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