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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803079
Report Date: 09/11/2024
Date Signed: 09/11/2024 03:19:27 PM

Document Has Been Signed on 09/11/2024 03:19 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 HOMEFACILITY NUMBER:
486803079
ADMINISTRATOR/
DIRECTOR:		PUNZALAN, ELPIDO A.FACILITY TYPE:
735
ADDRESS:913 JEFFERSON STREETTELEPHONE:
7074258165
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 3CENSUS: 3DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Virgina Punzalan, Designated Resposible PartyTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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At approximately 11:20 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and follow up on two special incident reports (SIRs) received by CCL on 6/15/2024 and 6/22/2024 and was greeted by Staff 1 (S1), Staff 2 (S2), and Staff 3 (S3). Virginia Punzalan, Designated Responsible Party (RP) was contacted and arrived at approximately 11:45 AM. Facility is an Adult Residential Facility with three (3) ambulatory clients in care. LPA was informed that Client 1 (C1) no longer attends Day Program and was present during today's inspection. LPA was informed that Client 2 (C2) and Client 3 (C3) were away at Day Program were and not present during today's visit. Facility is vendorized with North Bay Regional Center (NBRC).

At approximately 11:50 AM, LPA initiated a tour of the facility with RP and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens and paper products available to clients. Clients' bedrooms were inspected and observed to have all of the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. LPA advised RP to increase the amount of fresh fruit and vegetables available to clients in the facility. Medications were centrally stored and locked. There is a shaded area in the backyard with outdoor space for activities. LPA was informed that the clients discuss where they would like to go for weekend outings during the week and decided collectively on a weekly basis which activities to plan. LPA observed a laptop available to clients in care. Facility has internet available to clients in care and the phone was tested an operational during today's inspection.

Facility's fire extinguisher was observed charged and was last serviced May 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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 3
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: 09/11/2024
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Continued from LIC809...

Facility conducts quarterly disaster drills, and the most recent drill was conducted August 2024.
LPA observed facility's infection control plan and emergency disaster plan which was last updated July 2024. LPA observed a supply of PPE, emergency supplies, multiple first aid kits, and flashlights for emergency preparedness. RP states the facility does not have a backup generator.

At approximately 12:30 PM, LPA reviewed five (5) staff files and three (3) client files. Five (5) of five (5) staff files reviewed have all the required paperwork and proof of current First Aid and CPR training. Three (3) of three (3) client files reviewed have all the required paperwork. Staff coordinate medical and dental visits for the clients and take them to their appointments.

At approximately 1:50 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. LPA reviewed P&I monies and logs, which were organized and maintained and stored in accordance with regulation.

At approximately 2:20 PM, LPA discussed the SIRs received by CCL with RP as follows:

Incident #1: On 06/15/2024 CCL received an SIR regarding C1 not returning home after curfew. The police found them and brought them home. SIR states staff gave C1 dinner and additional food "in lieu of [...] bedtime medications being administered [...]". Today, Facility provided LPA a copy of C1s medication administration record (MAR) confirming that they were given their night time medications the evening of the incident. RP says it must have been a grammatical mistake.

Incident #2: On 06/22/2024 CCL received an SIR regarding C1 reporting to facility staff that they were bitten by a stray dog on their left arm. Staff responded immediately, picked up C1 and took them to the emergency room (ER) for treatment. Today, facility provided LPA proof that C1 received all the required antibiotics and rabies and tetanus shots. LPA observed C1 and confirmed that they are fully recovered.

continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 09/11/2024
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continued from LIC809C...

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC500 - Personnel Report (updated)

No deficiencies cited during today's inspection. Exit interview conducted with RP whose signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024
LIC809 (FAS) - (06/04)
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