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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601129
Report Date: 05/19/2022
Date Signed: 05/19/2022 12:21:18 PM


Document Has Been Signed on 05/19/2022 12:21 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:JLA HEALTHCARE SERVICES LLCFACILITY NUMBER:
415601129
ADMINISTRATOR:LEONARD, JEROMEFACILITY TYPE:
740
ADDRESS:1185 ACACIA STREETTELEPHONE:
(510) 313-3673
CITY:MONTARASTATE: CAZIP CODE:
94037
CAPACITY:24CENSUS: 0DATE:
05/19/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jerome Leonard and Eloisa BustamanteTIME COMPLETED:
12:30 PM
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On 5/19/22 at 10:00AM, Licensing Program Analyst (LPA), Murial Han met with the Administrators, Jerome Leonard and Eloisa Bustamante to conduct an announced Pre-Licensing inspection.

LPA observed the indoor and the outdoor passageways are free of obstruction.

Ms. Bustamante provided a tour of the facility.

This is a single level facility. There is no residents during the time of the inspection. LPA observed good lighting and comfortable temperature in the facility. LPA observed sufficient hygiene and cleaning supplies. Three trash cans in the kitchen have tight fitting, and foot operated lids. The refrigerator was measured at 39 degrees Fahrenheit (F) and the freezer was measured at -7 degrees F. LPA observed sufficient amount of non-perishable food, utensils, cooking wares and cleaning supplies. The first aid kit was inspected to be adequate.

LPA observed adequate postings including CCL complaint poster, resident's rights, resident council rights, the emergency disaster plan, facility theft and lost program.

LPA observed some COVID-19 signs within the facility but recommended to post hand washing instruction signs by the hand washing stations, and additional COVID-19 signs.

The facility has a spacious a dining room and a theater. A few resident's rooms were equipped with beds and furniture.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2022
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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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: JLA HEALTHCARE SERVICES LLC
FACILITY NUMBER: 415601129
VISIT DATE: 05/19/2022
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LPA observed bathroom sinks temperature measured at 106- 116 degrees Fahrenheit (F) and the main shower room was measured at 107 degrees Fahrenheit (F).

Pre-Licensing is incomplete during this inspection due to the following area of concerns:

- LPA observed the overall facility required cleaning as there were white powder and black particles identified in resident's room, bathrooms, shower room, dining room, kitchen, and hallways.
- LPA observed 3 non-skid mats were unopened next to the shower rooms
- LPA observed brown and rusty stains on the shower tubs
- LPA observed black stains inside the shower tubs
- LPA observed blurry and foggy windows throughout the facility
- LPA observed a mental bed frame with 2 mattresses positioned on the floor in room 103
- Facility has a laundry but no dryer and washer

The administrator acknowledged the above findings and stated that a professional cleaning crew is scheduled to come on May 22, 2022 for deep cleaning.

A follow-up pre-licensing inspection will be scheduled.

Exit interview conducted with administrator, Eloisa Bustamante and Jerome Leonard

A copy of this report is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC809 (FAS) - (06/04)
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