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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601129
Report Date: 11/06/2024
Date Signed: 11/06/2024 11:08:01 AM

Document Has Been Signed on 11/06/2024 11:08 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:JLA HEALTHCARE SERVICES LLCFACILITY NUMBER:
415601129
ADMINISTRATOR/
DIRECTOR:
LEONARD, JEROMEFACILITY TYPE:
740
ADDRESS:1185 ACACIA STREETTELEPHONE:
(650) 477-2857
CITY:MONTARASTATE: CAZIP CODE:
94037
CAPACITY: 24CENSUS: 22DATE:
11/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Loi BustamanteTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 11/6/2024, Licensing Program Analyst (LPA), Murial Han conducted an unannounced case management visit to follow-up on an incident that was reported by the facility. LPA met with the administrator and explained the purpose of today's visit.

On 10/8/2024, the facility reported that resident #1 (R1) reporting that resident #2(R2) hit him/her in the room and there was no witness. The facility completed a change of condition for R1 and reported the alleged incident to R1's responsible party, the Ombudsman and the physician. In addition, the facility completed an assessment for R1 and no injuries were noted. The facility also started hourly rounds on R1 and R2 to ensure their safety.

During today's visit, LPA observed R1 and R2 were pleasant and calm and the administrator reported that there were no more reporting of the alleged incident.

According to the administrator, both residents were new to the facility when this alleged incident was report and they are adjusting well now.

No deficiency is cited today.

This report is reviewed and discussed with the administrator.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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