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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202857
Report Date: 02/08/2024
Date Signed: 02/09/2024 01:05:01 PM


Document Has Been Signed on 02/09/2024 01:05 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:DJ'S CAREHOMEFACILITY NUMBER:
435202857
ADMINISTRATOR:REAL, JOCELYNFACILITY TYPE:
740
ADDRESS:4318 KINGSPARK DRIVETELEPHONE:
(408) 464-2245
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY:6CENSUS: 6DATE:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jocelyn RealTIME COMPLETED:
04:37 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with administrator (ADM) Jocelyn Real. 3 staff and 5 residents were observed in facility.

LPA reviewed 2 resident files and 2 staff files.

LPA toured the facility inside and out with ADM. License, personal right posters, and administrator certificate were observed at entrance. LPA inspected living room, kitchen, dinning area, laundry room and garage. Medication closet, knives closet, and cleaning product closet were observed locked. There are 3 shared resident rooms at first floor for residents, and 2 restrooms for residents at first floor. There are 3 staff live-in rooms, 1 office room, and 1 restroom at the second floor in facility. Room temperature was observed at 70 degree F, and hot water temperature was observed at 110 degree F. The temperature of the refrigerator was at 40 degree F, and the temperature of the freezer was at 0 degree F. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient.

The facility is equipped with smoke and carbon monoxide detectors. The facility equipped with fire alarm. ADM tested the smoke and carbon monoxide and fire alarm detectors, and they were working fine. The fire extinguishers were observed on service on 12/28/2023. LPA inspected the backyard, there was no obstruction to block the walkway. The facility conducted fire and emergency drill on 1/14/2024.

First aid box, flash lights and night light were observed in the facility.

Deficiencies noted for today's inspection. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
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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Document Has Been Signed on 02/09/2024 01:05 PM - 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: DJ'S CAREHOME
FACILITY NUMBER: 435202857

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above in that one of the resident's P&I money was observed less than $19.39, and another resident's P&I money was observed more than $43.68 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2024
Plan of Correction
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Administrator stated the facility will submit a plan of correction by the POC due date to develop a protocol/rule to make sure the P&I money and records were maintained accurately.
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: Romeo ManzanoTELEPHONE: (408) 324-2112
LICENSING EVALUATOR NAME: Chihhsien ChangTELEPHONE: (408) 904-9843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
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