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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004273
Report Date: 06/23/2023
Date Signed: 06/23/2023 03:50:15 PM


Document Has Been Signed on 06/23/2023 03:50 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
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:
06/23/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Juanito De La Cruz, CaregiverTIME COMPLETED:
04:00 PM
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LPA Campbell arrived to Facility on 06/23/23 at approximately 9 am and was met by Caregiver Juanito Dela Cruz. LPA Campbell explained the purpose of the visit and observed one resident in the dining room watching tv. The entryway to the dining room contained a dog crate, bags of dogfood were on the working table. Floors were clear of debris and Caregiver was observed mopping the floors in the kitching/dining room. Bathrooms were clean but there was the smell of urine which caregiver cleaned when he mopped the entire area

Two couches were in the living room along with a large plant and a coffee table. A television was in the main living room with the a small desk and facility documents were pinned to the wall. Pictures of the caregivers family were on the wall as well. In master bedroom #1 for ambulatory residents, R1 and R2 had a bathroom to themselves. R2 and R3 were in the ambulatory bedroom , two residents were in the non-ambulatory bedroom. LPA Campbell requested the resident files and LPA Albert Johnson began to review them and verify room assignments. It was found that Rwas a non-ambulatory resident in an ambulatory bedroom. The caregiver was made aware and corrected the placement during inspection. LPA Campbell requested staff files. The administrator, Arlyn De La Cruz has her current Administrator Certificate, health screening, cpr and tb results. Jackielyn De La Cruz has CPR credentials as well as her health screening and tb results. The current caregiver for the facility, Juanito De La Cruz also has his health screening, tb and cpr credentials. Jackielyn De La Cruz has agreed to provide Designation of Facility Responsibility for the facility once her mother returns on 06/29/23.

SUPERVISOR'S NAME: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
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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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
VISIT DATE: 06/23/2023
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While reviewing documents, LPA Albert Johnson stated he saw a roach on the table on the paperwork. Caregiver Juanito stated the facility had had an exterminator visit a month ago and provided a copy of the bill.

LPA Campbell observed the kitchen and refrigerator contents and found fruits and vegetables along with condiments and other items that were undated. There were enough perishables to last the facility for three days and enough non-perishables to last for seven days. LPA Campbell visited the backyard. Grass was cut low. The path to the backyard fire exit was clear with no obstructions. The wooden gate leading to the backyard had a latch but the latching post was very loose and could be pushed inward by 30 degrees and need either replacement or strengthening.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/26/2023:



LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate


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: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/23/2023 03:50 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
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: 06/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2023
Section Cited
CCR
87303(a)

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87303(a)Maintenance and Operation. The facility shall be clean, safe, and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by :
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Licensee will submit a plan for fixing the side gate post by POC date.
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Based on observation, the licensee failed to repair the wooden gate access so that it provided secure access to the side of the home.
Which poses a potential Health, Safety or Personal Rights risk to residents 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: Emerita CurielTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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