397004273-4-11-2022-27-AS-TWHE-CD8RVE-20220406132125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397004273
Report Date: 04/06/2022
Date Signed: 04/11/2022 07:49:28 AM

Document Has Been Signed on 04/11/2022 07:49 AM - 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 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:	04/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Juanito De La Cruz, Caregiver		TIME COMPLETED:	12:30 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 04/06/2022 at 9:55 AM, Licensing Program Analysts (LPAs) T. White and R. Campbell arrived unannounced to conduct a required 1-year annual inspection. LPAs met with Caregiver Juanito De La Cruz and explained the purpose of today’s inspection. LPAs were allowed entry into the facility that is licensed to serve a total capacity of 6 residents, of which 2 may be non-ambulatory. LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. A comfortable temperature is maintained at 73 degrees Fahrenheit. Hot water temperature measured at 115.3 degrees F. LPAs observed lighting in all rooms are adequate for the comfort and safety of the residents. There is a minimum of a 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 23, 2021. First aid kit was observed to be complete. LPAs reviewed 3 resident files and 1 staff record file. LPAs observed the following deficiencies: - LPA's observed expired food on top of the kitchen island. - LPAs observed unlocked medications in the kitchen cabinet. - LPAs observed expired medications not disposed correctly. - LPA's observed unwrapped meat in the freezer. 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: 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 04/11/2022 07:49 AM - 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above in 87465(h)(2). LPAs observed unlocked medications which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2022
	Plan of Correction
1 2 3 4	Caregiver locked medications. Administrator agreed to complete in-service training with staff regarding locked medications. Administrator will submit proof to CCLD by POC date.

Type A

Section Cited

CCR

87465(i)

(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above in 87465(i). LPAs observed expired medication not properly disposed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/13/2022
	Plan of Correction
1 2 3 4	Facility agreed to properly dispose medication 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: 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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Document Has Been Signed on 04/11/2022 07:49 AM - 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not comply with the section cited above in 87555(b)(8). LPAs observed expired canned goods and meat not properly packaged which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/14/2022
	Plan of Correction
1 2 3 4	Caregiver removed expired food and threw away packaged meat. Deficiency cleared during inspection

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: 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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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: 04/06/2022

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 04/15/2022:

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

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

Exit interview conducted with Caregiver. A copy of report and Appeal Rights given.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana White	TELEPHONE: (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

LIC809 (FAS) - (06/04)

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