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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004273
Report Date: 04/06/2022
Date Signed: 04/06/2022 01:26:06 PM


Document Has Been Signed on 04/06/2022 01:26 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:J & M CARE HOMEFACILITY NUMBER:
397004273
ADMINISTRATOR:ARLYN DE LA CRUZFACILITY TYPE:
740
ADDRESS:5766 FRED RUSSO DRIVETELEPHONE:
(209) 915-3962
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 4DATE:
04/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Juanito De La Cruz, CaregiverTIME COMPLETED:
01:40 PM
NARRATIVE
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On 04/06/2022, Licensing Program Analysts (LPA),T. White and R. Campbell, conducted an unannounced case management visit to follow up on an AWOL incident, which occurred on 03/10/2022. LPA met with Caregiver, Juanito De La Cruz and explained the purpose of the visit.

LPA White reviewed the incident report submitted to CCLD on 03/10/2022. Based on incident report, Resident #1 (R1) took the shuttle bus to his doctor's appointment and decided he did not want to return to the facility after appointment. R1 contacted Case Manager after appointment to inform her that he did want to return to the facility. R1 decided he wanted to stay in a motel for the night. Staff #1 (S1) stated the Case Manager was unable to contact R1 the next day. S1 decided to contact law enforcement regarding missing person.

Based on interview, R1 decided to come back to the facility on 04/02/2022. Based on R1's Physician Report, R1 is unable to leave unassisted. LPA observed R1 at the facility. LPA reviewed how the facility is working with residents to prevent further AWOLs.

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

Exit interview was conducted with Caregiver. A copy of report and appeal rights given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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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Document Has Been Signed on 04/06/2022 01:26 PM - It Cannot Be Edited

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: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2022
Section Cited

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87411(a): Personnel Requirements- General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement was not met as evidence by:
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Based on record review, the facility did not comply with section 87411(a). Based on record review, R1 AWOL'd from the facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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