486803079-10-5-2023-21-AS-CFOR-CWBV8B-20231005161229

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803079
Report Date: 10/05/2023
Date Signed: 10/05/2023 04:12:35 PM

Document Has Been Signed on 10/05/2023 04:12 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	RED JADE HOME		FACILITY NUMBER:	486803079
ADMINISTRATOR:	PUNZALAN, ELPIDO A.		FACILITY TYPE:	735
ADDRESS:	913 JEFFERSON STREET		TELEPHONE:	(707) 425-8165
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY: 3		CENSUS: 3	DATE:	10/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:07 PM
MET WITH:	Remedios Isla, Caregiver		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Carol Fowler is conducting an Required-1 Year inspection, on 10/05/2023 at approximately 12:07PM, and met with Remedios Isla, Caregiver and Virginia Punzalan, Co-Administrator arrived approximately 12:32PM LPA observed one staff on duty on arrival. Currently three (3) client in care. Facility has an approved fire clearance three (3) ambulatory clients. The facility has required emergency disaster plan. Facility scheduled evacuation fire drill will be 10/06/2023, including staff & client. Client, 1 out of 3, special diets regarding food are followed per staff interviews, and per LPA's observations during the inspection. The LPA reviewed four (4) staff files. Administrator certificate for Virginia Punzalan is current-CERT# 6006324735 expires 1/1/2025. All staff have required criminal record clearance. All staff have required training. The LPA reviewed three (3) client files. Client files were complete. P&I clients monies were maintained as required, and not mixed with facility funds/any other funds. The LPA toured the facility with the Administrator. All exits were unobstructed. The facility fire extinguisher was serviced and tagged as required expires 05/20/2023. Facility had eight (8) smoke alarms, and all were working properly when checked during the inspection. Facility had one (1) carbon monoxide detector that were working properly when checked during the inspection. Facility had a first aid kit stored in the hallway and one locked in storage, it did have a required first aid booklet. The facility had a first aid kit, and first aid booklet. The facility had a sufficient supply of perishable and nonperishable food. Continue on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RED JADE HOME	FACILITY NUMBER: 486803079
	VISIT DATE: 10/05/2023

NARRATIVE

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The facility had food, water, and emergency supplies to meet the 72 hour shelter in place requirement. The facility had a sufficient supply of personal protective equipment(PPE) for use as needed. The facility had a sufficient supply of hygiene supplies, cleaning supplies, and paper products for use as needed. The LPA observed the facility to be clean and orderly during the visit. The LPA observed that resident rooms, common areas, hallways, and bathrooms had sufficient lighting for clients in care. Clients rooms had required accommodations per regulations.

Deficiencies observed by LPA

Facility had medication closet unlocked and accessible to clients in care.
Facility had chemicals unlocked under the kitchen sink and accessible to clients in care.

LPA is requesting the following forms be updated and submitted to CCL by 10/16/23:

· LIC 500 -Personnel Report
· LIC 610D - Disaster Plan
· LIC 308 - Designation of Responsibility
· LIC 308 - Copy of Administrator Certificates
· Affidavit Regarding Client Cash Resources
· Copy of Surety Bond in Required Amount
· Infection Control Plan If updated

Control of property

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/05/2023 04:12 PM - It Cannot Be Edited

Created By: Carol Fowler On 10/05/2023 at 03:55 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: RED JADE HOME	FACILITY NUMBER: 486803079
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80075(k)(1)

(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, The licensee did not comply with the section cited above and Medication closet was unlocked. This poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/07/2023
	Plan of Correction
1 2 3 4	Staff immediately secured the medication. POC cleared at time of visit. Administrator will train all staff on regulation 80075(k)(1) and submit a copy with date, time, duration, subject, attendees and their signatures to Community Care Licensing (CCL) by POC date

Type A

Section Cited

CCR

80087(g)

80087 Buildings and Grounds - (g) Disinfectants, cleaning solutions, poisons, ... and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having chemicals unlocked and accessible to clients in care which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/07/2023
	Plan of Correction
1 2 3 4	Administrator will train all staff on regulation 80087(g) and submit a copy with date, time, duration, subject, attendees and their signatures to Community Care Licensing (CCL) by POC date. chemicals locked during visit.

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 Mota

LICENSING EVALUATOR NAME:

Carol Fowler

LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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