486803977-9-14-2022-21-AS-ACAA-CJ9VGY-20220914162618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803977
Report Date: 09/13/2022
Date Signed: 09/14/2022 04:26:31 PM

Document Has Been Signed on 09/14/2022 04:26 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

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: 5	DATE:	09/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:12 AM
MET WITH:	Evelyn Serrano, Licensee		TIME COMPLETED:	01:30 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) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Licensee, Evelyn Serrano. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly. There are currently 5 residents in care. This facility is licensed for 6 non ambulatory residents, with hospice waiver approved for 3 of the residents and none of the residents are approved for bedridden. LPA toured facility and grounds and observed COVID-19 precaution signs posted in common areas. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms upon arrival to the facility. Infection control practices are present: entry procedures, face coverings, and 30-day PPE supply. Facility to follow indoor visitation requirement of verifying and tracking COVID-19 vaccination or verify non-essential visitors have proof of a negative COVID-19 test. Facility to start logging daily monitoring and temperatures checked for residents and staff. Facility states staff clean and disinfect the facility daily. Bathrooms are equipped with liquid soap and paper towels and required hand washing postings. Covid-19 Mitigation plan was reviewed by Community Care Licensing department on 12/27/2021. Facility has also submitted their Infection Control plan, that will be part of their plan of Operation. Caregivers have completed PPE training and have not been N-95 Fit tested. In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. LPA consulted regarding facility having at least two days of perishable and more than one week of non-perishable foods and food items should meet any residents dietary restrictions as per Physicians orders. There were 4 fire Extinguisher found to be charged, 3 with no service tags and one purchased 6/1/2021. LPA went over requirements of yearly service for all extinguishers in the facility. Continue report see LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

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: JPS HOME CARE SERVICES	FACILITY NUMBER: 486803977
	VISIT DATE: 09/13/2022

NARRATIVE

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LPA requested facility to submit paperwork for a change in Administrator to LPA Canela by 9/20/2022.

LPA went over reporting requirements.

LPA also requested the following updated records to be submitted to Community Care Licensing by 10/2/2022

· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610D Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
· Copy of current Administrator's Certificate
· Copy of Liability Insurance
· Copy of current Lease/Rental Agreement or Property Tax document showing control of property.

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. Appeal rights provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/14/2022 04:26 PM - It Cannot Be Edited

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: JPS HOME CARE SERVICES	FACILITY NUMBER: 486803977
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87203

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on today's inspection and observation with licensee, Evelyn Serrano, the licensee did not comply with the section cited above in 4 out of 4 fire extingueshers had not been serviced within the last year,which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2022
	Plan of Correction
1 2 3 4	Facility to send proof all fire extingueshers have been serviced yearly with proof of service tags. In addition, facility to send in a written statement they understand regulation requirement and how they will insure they follow it. POC due date 9/20/2022 to CCL attention LPA Canela

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022

LIC809 (FAS) - (06/04)

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