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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004273
Report Date: 06/20/2023
Date Signed: 06/21/2023 09:44:33 AM


Document Has Been Signed on 06/21/2023 09:44 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
SACRAMENTO AC/SC, 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) 915-3961
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY:6CENSUS: 4DATE:
06/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
07:45 PM
MET WITH:Juanito De La CruzTIME COMPLETED:
08:45 PM
NARRATIVE
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Licensing program analyst (LPA) Kesha Lewis and Regional Manager (RM) Stephenie Doub made an unannounced visit to the facility on this day for the purpose of conducting a Case Management - Deficiencies visit. RM arrived at the facility and met with Caregiver Juanito De La Cruz. RM explained the purpose of the visit.

At approximately 4:45 PM a social worker from the San Joaquin County Ombudsman's office arrived at the facility to find 6 residents in the facility and there was no staff present. The Ombudsman notified the Regional Office that there was not staff present. The RO attempted to contact licensee as well as call the facility but all numbers went to voicemail which said that the mailbox was full. At approximately 6:00 PM, the RO was able to contact Juanito De La Cruz who advised that he was at the licensee's other facility. The RO asked inquired about the staff at this facility. Juanito hung up with the RO staff, arriving at this facility at approximately 6:15 PM.

(LPA) Kesha Lewis and RM Doub arrived at the facility at approximately 6:30 PM. (LPA) Kesha Lewis and RM Doub asked Caregiver De La Cruz why there wasn’t any staff at the facility for over an hour and a half. Caregiver De La Cruz stated that there was an emergency at the other facility and he had to go over there.

(LPA) Kesha Lewis and RM Doub toured the interior of the facility and interviewed four residents. Per Resident 1 (R1), he could not confirm if the staff had left the facility unstaffed prior only stating that Juanito has to go shopping and run errands. R1 continued reporting that Juanito will ask Arlyn or their daughter come when he needs to leave but currently Arlyn is on vacation. Sometimes R2 will have to call Juanito because he is not at the facility.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were cited during this visit.



An exit interview was conducted, report given. Kesha.lewis@dss.ca.gov
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/21/2023 09:44 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
SACRAMENTO AC/SC, 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: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2023
Section Cited
CCR
87464(f)(1)(c)

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Basic Services (c) "Care and supervision" means the facility assumes responsibility for, or provides... assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes ...personal care.
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Licensee will review the regulation listed and submit a letter of understanding on basic services, and care and supervision to the department by COB on 6/21/2023.
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This requirement was not met as evidenced by: based on witness observation by the ombudsmen office. This poses an immediate health and safety risk to resident.
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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: Kesha LewisTELEPHONE: (650) 676-0552
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2