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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801888
Report Date: 09/17/2024
Date Signed: 09/18/2024 08:17:21 AM


Document Has Been Signed on 09/18/2024 08:17 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:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Rafael and Rose Aquino, AdministratorsTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct a Required - 1 Year inspection and met with Administrator/Licensee, Rafael and Rose Aquino. There are currently 5 residents in care. There were 2 staff at the time of inspection. 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 the home organized and at a comfortable temperature with all exits free from obstruction. Exit doors have auditory alarms to alert staff. The fire extinguisher located in the kitchen was observed charged and serviced on 09/10/2024. Fire drills have not been documented. LPA requested Fire Drill to be conducted and proof sent to CCL. Water temperature in the resident bathroom was tested and found to be within appropriate range of 105-120 degrees. Bathrooms have required non-skid surfaces and grab bars. Cleaning products and knives are stored in locked cabinets in the kitchen and the laundry room.

There was a 7 day supply of non-perishable foods. There are adequate dishes, glasses and silverware. Residents' medications are stored locked. Resident and staff files are located and locked in cabinet. LPA reviewed staff files and staff have proof of CPR/1st aid. LPA requested proof of yearly training. Resident files were reviewed and found to be complete, except for Consent for Medical Treatment. LPA left copies for each resident/DPOA to complete.

Continued on 809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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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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: 09/17/2024
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Continued from 809

Licensee/Administrator to submit the following documents by 10/10/24:

· LIC 500 Personnel Report
· Proof of Staff Trainings
· Copy of Liability Insurance

and Documentation of Emergency Drills

No citations issued at this time.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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