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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601129
Report Date: 05/05/2026
Date Signed: 05/05/2026 02:29:14 PM

Document Has Been Signed on 05/05/2026 02:29 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
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: 21DATE:
05/05/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Loi BustamanteTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 5/5/2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management Health and Safety visit to follow up on an incident report that was report to CCL. Upon entry, LPA was greeted by Registered Nurse Araceli Aguilar and Administrator Assistant, Julie Gossage and LPA explained the purpose of today's visit. The administrator arrived towards the middle of the visit and assisted with the rest of the visit.

During the visit, the administrator assistant provided a tour of the facility and LPA observed the exit door by room 103 was broken and not able to close, LPA observed 3 rooms (205, 303, and 305 ) were converted into staff rooms and staff #1 (S1) reported that the resident's shower room by the bathroom is being shared with the live-in staff members; LPA observed the laundry room consisted of chemicals was unlocked and unattended by staff; LPA observed bath tub in the shower room between room 301 and 302 was dirty, brown stains by the grab bar, hair inside the tub, white particles around the faucets and no non-skid mat; LPA observed resident #1 (R1) and resident #2 (R2) required oxygen and there was no “no smoking sign” posted, LPA observed resident #3 (R3) has a prohibited health condition in which the facility did not notify CCL and requested for an exception.

LPA requested for an updated facility sketch reflecting the current room status as some of the resident rooms were converted into staff rooms and provide a copy of the updated sketch to CCL by 5/14/2026.

Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the administrator.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/05/2026 02:29 PM - It Cannot Be Edited


Created By: Murial Han On 05/05/2026 at 11:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JLA HEALTHCARE SERVICES LLC
FACILITY NUMBER: 415601129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2026
Section Cited
CCR
87309(a)

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87309 Storage Space and Access a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions,..a danger to residents are in locked storage and are not left unattended if outside the locked storage.
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The administrator will develop a plan to ensure chemicals are locked and inaccessible to residents at all times. The plan of correction shall include staff education. The administrator will
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The requirement is not met as evidenced by LPA observed on 5/5/2026, during the facility tour, LPA observed the laundry room filled with chemicals was unlocked and accessible to residents in care which poses an immediately health and safety risks to residents in care.
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submit a copy of the plan of correction and staff in-service to CCL by 5/6/2026.
Type A
05/06/2026
Section Cited
CCR87616(a)

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87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
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The administrator will review the regulation and develop a plan of correction on how the facility is going to prevent this from happening again. The administrator will provide a copy of the plan of correction by 5/6/2026.
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This requirement is not met as evidenced by during the tour of the facility, LPA observed R3 has a sign of contact isolation posted on the door but the facility did not notify CCL which poses an immediately health and safety risks to residents in care.
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The administrator will obtain documentation from resident's provider to clarify if resident shall remain on isolation and will communicate with CCL by 5/8/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/05/2026 02:29 PM - It Cannot Be Edited


Created By: Murial Han On 05/05/2026 at 11:42 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JLA HEALTHCARE SERVICES LLC
FACILITY NUMBER: 415601129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2026
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation..(a)The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as during the facility tour, LPA observed the exit door by room 103 was broken and not able to close. LPA observed the shower tub between
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The administrator will call the contractor today to fix the exit door and the administrator will clean the shower room by room 301 and 302.
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rooms 301 and 302 was dirty which poses an immediately health and safety risks to residents in care.
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The administrator will take photos of the shower room between 301 and 302 and submitted to CCL by 5/6/2026 and will provide photos for the exit door by 5/12/2026.
Type A
05/06/2026
Section Cited
CCR87618(b)(3)(B)

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87618 Oxygen Administration - Gas and Liquid (b)In addition to Section 87611(b), the licensee shall be responsible for the following:(3) Ensuring that the use of oxygen equipment meets the following requirements:
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During the visit, LPA observed the "no smoking signs" were posted resident's rooms. The administrator will develop a plan of correction to ensure signs are posted accordingly and will provide a copy of the plan to CCL by 5/6/2026.
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(B) "No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement is not met as evidenced by during the tour of the facility, LPA observed R1 and R3 required oxygen and LPA did not observed "no smoking signs" posted by the room and around the area which poses an immediate health and safety risks 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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/05/2026 02:29 PM - It Cannot Be Edited


Created By: Murial Han On 05/05/2026 at 11:54 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JLA HEALTHCARE SERVICES LLC
FACILITY NUMBER: 415601129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2026
Section Cited
CCR
87618(b)(3)(A)

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87618 Oxygen Administration - Gas and Liquid (b)In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements:
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The administrator will develop a plan of correction to ensure the local fire jurisdiction is notified accordingly when oxygen is in use at the facility and will provide a copy of the written notices for R1 and R2. The administrator
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(A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. This requirement is not met as LPA observed R1 and R3 requires oxygen and the administrator stated that the local fire jurisdiction was not notified of the oxygen usage.
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will provide a copy of the notification and a copy of the plan of correction to CCL by 5/14/2026.
Type B
05/14/2026
Section Cited
CCR87307(a)

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87307 Personal Accommodations and Services(a) Living accommodations and grounds.. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility..
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The administrator will develop a plan to ensure staff and resident are not sharing a common shower room and will provide a copy of the plan to CCL by 5/14/2026.
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This requirement has not been as evidenced by during the tour of the facility, staff #1 (S1) reported that the resident's shower room by the bathroom is being shared with the live-in staff members which poses an immediate health and safety risks 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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2026


LIC809 (FAS) - (06/04)
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