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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004273
Report Date: 05/09/2023
Date Signed: 05/09/2023 11:59:52 AM


Document Has Been Signed on 05/09/2023 11:59 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: 6DATE:
05/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Juanito De La Cruz, Caregiver/OwnerTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced Annual 1-Year required visit on this date. LPA met and toured with Juanito De La Cruz the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 total bedrooms of which 3 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 120 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. 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 visit. Fire extinguisher was last serviced on December 19, 2022. Emergency Disaster Plan was last posted on 04/13/2022. First aid kit was observed to be complete. Fire drill was last conducted on March 11, 2023.

All staff present were cleared and are associated to the facility. Based on prior deficiencies for the facility, LPA inspected all client medications and MAR, ensured dangerous items were secured and checked for the presence of expired food and other potential hazards. LPA Campbell reviewed 3 of 3 residents’ files..

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 ,and California Health and Safety Code. Failure to correct deficiencies may result in civil penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
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 is an Amendment of Original Document on 05/11/2023 02:40 PM

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: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 1 carbon monoxide alarms.There is no carbon monoxide detector, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2023
Plan of Correction
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Licensee will purchase a carbon monoxide alarm today and provide a proof of purchase with a copy of a receipt and an image of the installed carbon monoxide alarm by end of day on 05.09.2023
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2023
LIC809 (FAS) - (06/04)
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