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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801888
Report Date: 09/30/2022
Date Signed: 09/30/2022 04:09:33 PM


Document Has Been Signed on 09/30/2022 04:09 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
09/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Rafael AquinoTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Administrator/Licensee, Rafael Aquino. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. There are currently 6 residents in care. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 1 of the resident and none of the residents are approved for bedridden.

LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, daily monitoring and temperatures checked for residents and staff, and 30-day PPE supply. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels. Covid-19 Mitigation plan was reviewed by Community Care Licensing department on 7/28/2021. Caregivers have completed PPE training but have not been N-95 Fit tested.

In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguisher was found to be charged but last serviced on 4/29/2021 and not within the required yearly service.
LPA consulted with Administrator, Rafael Aquino regarding a loose or weak board in the front entrance wooden path that will need to be looked at and repaired.

Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: JENSTEPH HOME CARE
FACILITY NUMBER: 486801888
VISIT DATE: 09/30/2022
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LPA requested copies of the following updated records to be submitted to Community Care Licensing by 10/30/2022.


· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Administrator's Certificate
· Copy of Liability Insurance
· Copy of current facility sketch
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.



Deficiencies cited (see LIC809-D page) from Title 22, Division 6 of California Regulation. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator, whose signature below confirms receipt of report.
Due to printer issues, this report was emailed to Administrator. Appeal Rights Provided

Exit interview conducted with Rafael Aquino Licensee/Administrator.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/30/2022 04:09 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: JENSTEPH HOME CARE

FACILITY NUMBER: 486801888

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 09/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on today's inspection and review of the fire extinguisher tag with administrator, Rafael Aquino. The licensee did not comply with the section cited above in 1 of 1 fire extinguishers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2022
Plan of Correction
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Facility to send in proof of serviced fire extinguisher and written plan on how they will ensure they meet regulation requirements. POC due date 11/2/2022
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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022
LIC809 (FAS) - (06/04)
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