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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801888
Report Date: 02/15/2024
Date Signed: 02/15/2024 11:44:33 AM


Document Has Been Signed on 02/15/2024 11:44 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
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: 5DATE:
02/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Rose AquinoTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst Leibert arrives unannounced following a complaint investigation which resulted in LPA noting some deficiencies that were not enumerated in the complaint allegations. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Report Left.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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 2


Document Has Been Signed on 02/15/2024 11:44 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
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: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2024
Section Cited
CCR
87625(b)(3)

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87625(b)(3) Managed Incontinence. ..The Licensee shall be responsible for…ensuring that incontinent residents are kept clean and dry..***Based on statement and observation, this requirement not met as evidenced by: On 1/23/24 LPA observed R1 had not been
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Administrator to provide refresher training to caregivers on the requirements of 87625 and will submit proof of training to CCL by POC date in order to clear the deficiency.

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changed at 9:45 am when other residents present were changed at 6 am. Staff stated that Hospice aid would change R1 when aid arrives. This posed an immediate violation of R1 personal rights and risk to health.
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Type B
02/29/2024
Section Cited
CCR87465(C)(3)

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87465(C)(3) Incidental Dental and Medical Care. A record of each dose (of PRN medication) is maintained in the resident's record. *** Based on observation and statements, this requirement has not been met as evidenced by: On 1/18/2024, LPA noted

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Administrator will provide refresher training to caregivers regarding the requirements of 87465 and will submit proof of training to CCL by POC date in order to clear the deficiency.
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that there was no record of PRN medications administered to R1 and that staff stated PRN meds were administered but not recorded. This posed a potential risk to the health of R1.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2