486803977-8-13-2021-21-AS-MCUA-C5UR73-20210813124542

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803977
Report Date: 08/13/2021
Date Signed: 08/13/2021 12:46:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	JPS HOME CARE SERVICES		FACILITY NUMBER:	486803977
ADMINISTRATOR:	PIMENTEL, LOLITA		FACILITY TYPE:	740
ADDRESS:	441 NORTH CAMINO ALTO		TELEPHONE:	(707) 655-2264
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY:	6	CENSUS: 0	DATE:	08/13/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Evelyn Serrano (Licensee)		TIME COMPLETED:	12:45 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) Cuadra arrived announced to conduct a Pre-licensing Inspection and Component III. LPA met with Applicant, Evelyn Serrano. LPA conducted risk assessment call prior to conduct the visit. LPA/Licensee toured the inside of the facility and grounds. LPA toured the facility with applicant Evelyn and observed the following. This is a one story residence with six bedrooms, two bathrooms, living room, family area room, master bedroom (resident's room), kitchen and dining eating area. Auditory alarms are on exit doors that were operational. Fire clearance granted by Vallejo Fire Department on 6/22/2021, granting capacity of six non-ambulatory. All rooms and common area had sufficient lighting, including hallways. The smoke alarms are hardwired and observed operational during inspection. Carbon Monoxide Detector observed and functioning. LPA observed fire extinguishers charged. Water temperature was measured at 106.2 F. LPA discussed per regulation water to be between 105 & 120 degrees F. There is a locked cabinet that will be used for medications. Binders for residents, staff and medication were observed in lockable cabinet. LPA informed cleaning supplies and toxins will be locked in a cabinet in the garage. Amble supply of linens, hygiene products, cooking utensils, pots/pans and dishes observed. Perishable and non-perishable foods observed per regulation. All bathrooms have non-skid flooring in showers. There is a seat on the shower for resident use for bathing. All appliances in the kitchen were working properly. Residents bedrooms had the required furnishings, such as a dresser, night stand, lamp and bed linens. LPA toured the large backyard area. Applicant informed LPA that facility won't handle cash for residents. Lolita's Pimentel Administrator Certificate 6018367740 expires 7/11/2022. LPA discussed facility's Disaster Preparedness with Applicant including observing their Emergency supplies. Applicant showed LPA the contents of their First Aid Kit. Continues on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: JPS HOME CARE SERVICES	FACILITY NUMBER: 486803977
	VISIT DATE: 08/13/2021

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Continued from LIC809...

LPA observed required postings (LTCO, CCL Complaint poster, visitor policy, employee rights and personal rights). in addition to COVID-19 required visitation postings. Facility has a sanitation station set up at the entrance to the facility in order to comply with Covid-19 precautions. Facility will be screening staff, residents and visitors for symptoms. The facility staff was observed wearing mask during the visit. Facility will provides assistance with family communication via telephone or video call. LPA reviewed their Mitigation Plan during this visit and approved.

Component III Orientation was completed with Applicant. Pre-licensing passed and COMP III completed. Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation. LPA will provide this report to the Centralized Application Unit to continue application process.

No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021

LIC809 (FAS) - (06/04)

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