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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600755
Report Date: 05/28/2021
Date Signed: 05/28/2021 06:29:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:J AND V FAMILY CARE HOMEFACILITY NUMBER:
415600755
ADMINISTRATOR:ANDAYA, JULITA DFACILITY TYPE:
740
ADDRESS:329 SAN PABLO AVENUETELEPHONE:
(650) 952-5231
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:6CENSUS: 6DATE:
05/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Tess Flores and Ellie Dela Cruz and Julita AndayaTIME COMPLETED:
06:30 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Julita Andaya is a certified RCFE administrator (x 2/23) that oversees facility operations.

The following updated forms/information are requested to be submitted to CCLD BY 6/4/21:

• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• LIC 999 Facility Sketch
• LIC 610D Emergency Disaster Plan
• Proof of current liability insurance

Ms. Andaya is advised that Personal Rights form (LIC613C-2) has been revised to include Health and Safety Code 1569.269, non-discrimination (LGBTQ) notice, AND Centralized Complaint and Information Bureau (CCIB) contact information. This information must be posted prominently in facility, and LIC613C-2 must be signed by resident or his/her representative.

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: J AND V FAMILY CARE HOME
FACILITY NUMBER: 415600755
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as there are no individual signs for infection control reminders: face coverings, social distancing, cough etiquette, and frequent hand washing, including signs at all hand washing sinks. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/01/2021
Plan of Correction
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Individual signs for infection control reminders must be posted prominently, and proof of correction to be submitted to CCLD BY DUE DATE.
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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 05/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2021
LIC809 (FAS) - (06/04)
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