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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601129
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:37:47 AM


Document Has Been Signed on 11/01/2022 11:37 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
SF COASTAL AC/SC, 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: 12DATE:
11/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Eloisa BustamanteTIME COMPLETED:
11:45 AM
NARRATIVE
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On November 1, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit. LPA met with Administrator, Eloisa Bustamante and explained the purpose of the visit.

During complaint control # 14-AS-20220607085541, the Department found that Staff #1 (S1) and Staff #2 (S2) was not fingerprint cleared and associated to the facility, however was providing care and supervision to residents in care.

During the visit, LPA spoke to the administrator and reviewed facility personnel records. Based on the records reviewed, it was observed that S1 and S2 are fingerprint cleared, however are not associated to the facility. A civil penalty of $100.00 for EACH individual is being assessed during the visit = $200.00.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrator and a copy is provided with appeals rights. Civil penalty is provided as well.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
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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Document Has Been Signed on 11/01/2022 11:37 AM - 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
SF COASTAL AC/SC, 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: 11/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2022
Section Cited

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Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

Violation of this regulation is evidenced by:
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Based on records review, facility failed to request a transfer of criminal record clearance for S1 which poses an immediate health and safety risk to residents in care.

On 11/1/2022, LPA confirmed with Administrator that S1 and S2 is still employed with facility and is providing care and supervision to residents. In addition, LPA observed S1 and S2 during the visit providing care and supervision.
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Immediate civil penalty of $100 is assessed for EACH individual.

$200.00 is being assessed during the visit

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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
LIC809 (FAS) - (06/04)
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