397004273-5-14-2021-27-AS-TWHE-C2ZSJX-20210514135552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004273
Report Date: 05/14/2021
Date Signed: 05/14/2021 04:17:53 PM

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:	J & M CARE HOME		FACILITY NUMBER:	397004273
ADMINISTRATOR:	ARLYN DE LA CRUZ		FACILITY TYPE:	740
ADDRESS:	5766 FRED RUSSO DRIVE		TELEPHONE:	(209) 915-3962
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95212
CAPACITY:	6	CENSUS: 4	DATE:	05/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Arlyn De La Cruz, Administrator		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 05/14/2021 at 12:10pm, Licensing Program Analyst (LPA) T. White spoke with Administrator, Arlyn De La Cruz regarding facility risk assessment questions. Administrator confirmed no staff or clients have experienced symptoms within the last 10 days. At 12:15pm, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Administrator and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. A comfortable temperature is maintained at 75 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on December 10, 2020. First aid kit was observed to be complete. LPA reviewed mitigation plan with Administrator. - LPA observed three screw drivers and 5 screws in unlocked kitchen drawer. - LPA observed knobs missing on kitchen stove. - LPA observed unlocked cleaning solution located in 2 of 4 resident rooms. - LPA observed scissors located in resident's room accessible to residents in care. - LPA observed a hammer in the backyard accessible to residents. - LPA observed unlocked tools in the garage accessible to residents in care. - LPA observed ramp is a potential hazard to residents in care. LPA observed ramp had missing wood which could be a tripping hazard. Report continues on 809C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

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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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: J & M CARE HOME	FACILITY NUMBER: 397004273
	VISIT DATE: 05/14/2021

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 05/28/2021:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

LPA had printer issues and will submit report and appeal rights via email. Exit interview conducted with Administrator.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

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: J & M CARE HOME	FACILITY NUMBER: 397004273
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/14/2021

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
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 87309(a). LPA observed screw drivers, tools, scissors, cleaning solutions, and hammers which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/14/2021
	Plan of Correction
1 2 3 4	Adminsitrator removed tools and cleaning solutions and locked it away. Adminsitrator agreed to complete in-service training and submit proof to CCLD by 05/28/2021

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: J & M CARE HOME	FACILITY NUMBER: 397004273
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above in87303(a). LPA observed 2 missing knobs on kitchen stove which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/21/2021
	Plan of Correction
1 2 3 4	Administrator agreed to provide knobs for kitchen stove and submit photo to CCLD by POC date.

Type B

Section Cited

CCR

87307(d)(4)

Personal Accommodations and Services

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in 87307(d)(4). LPA observed missing wood from backyard ramp which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/28/2021
	Plan of Correction
1 2 3 4	Adminsitrator agreed to repair missing wood from ramp and submit proof to CCLD by POC date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2021

LIC809 (FAS) - (06/04)

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