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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801888
Report Date: 07/30/2021
Date Signed: 07/30/2021 09:38:17 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:JENSTEPH HOME CAREFACILITY NUMBER:
486801888
ADMINISTRATOR:AQUINO, RAFAEL V.FACILITY TYPE:
740
ADDRESS:736 ANITA CIR.TELEPHONE:
(707) 747-6659
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY:6CENSUS: 6DATE:
07/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Caregiver, Violeta Navarro
Administrator, Rafael Aquino
TIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of conducting a Required 1-year inspection. LPA was met at the door by Caregiver, Violeta Navarro. Caregiver granted access into the home. Administrator, Rafael Aquino arrived at the facility 20 minutes later.

LPA toured the facility and found the facility was a comfortable temperature, free from obstructions. and was well lit. Extra hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature in resident's bathrooms measured within acceptable range of 105 to 120 degrees F. Cleaning products and other toxins are located in the locked laundry room. Knives are located in a locked cabinet in the kitchen. Perishable and non-perishable foods were sufficient and well labeled, with a 2 day supply of perishable foods, and a 7 day supply of non-perishable foods, as required. Medications were centrally stored and locked. Residents handle their own cash resources. Fire extinguisher located in the kitchen was last inspected April 2021. Smoke detectors were located throughout the facility and carbon monoxide detector were tested and functional. Exit doors have auditory alert system. The last Disaster Drill was conducted March 2021.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has Personal Protective Equipment (PPE) supplies with the exception of disposable gowns. LPA gave disposable gowns to the facility and requested facility stock up on PPE. Staff have had all PPE training required and is in the process of acquiring N95 Fit testing.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator, Rafael Aquino.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021
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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