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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803977
Report Date: 09/14/2021
Date Signed: 09/15/2021 11:14:19 AM

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 SERVICESFACILITY NUMBER:
486803977
ADMINISTRATOR:PIMENTEL, LOLITAFACILITY TYPE:
740
ADDRESS:441 NORTH CAMINO ALTOTELEPHONE:
(707) 655-2264
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:6CENSUS: 5DATE:
09/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:10 PM
MET WITH:Evelyn SerranoTIME COMPLETED:
06:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) A. Canela arrived to JPS Home Care Services unannounced regarding a complaint investigation. LPA observed Individual (I1), providing care/assistance to residents in the facility.
LPA verified through the facility Guardian Personal Report/Roster that I1 had a fingerprint clearance but was not associated to JPS Home Care Services as required.

Licensee stated they understood CCL's requirements and prior to anyone working, providing care, volunteering, or residing at JPS Home Care Services, the individual must obtain a fingerprint clearance and be associated to the facility.

Civil penalty in the total amount of $100.00 was issued today for individual (I1) not being associated to this facility as required.

Appeal Rights Provided.
Deficiencies 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 with Evelyn Serrano. Due to printer issues this report and Appeal rights will be emailed to Licensee.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2021
Section Cited

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87355 (e)(2) - Criminal Record Clearance
(e) All individuals subject to a criminal record review...(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance...
This requirement was not met as evidenced by:
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Based on record review, observations, and interviews conducted: Facility did not request a transfer of a criminal record clearance for individual (I1) prior to working at the facility.
This is an immediate safety risk to the residents in care.
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**Civil Penalty assessed in the amount of $100.00

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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021
LIC809 (FAS) - (06/04)
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