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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803977
Report Date: 09/15/2023
Date Signed: 09/18/2023 06:29:59 PM


Document Has Been Signed on 09/18/2023 06:29 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 SERVICESFACILITY NUMBER:
486803977
ADMINISTRATOR:PIMENTEL, LOLITAFACILITY TYPE:
740
ADDRESS:441 NORTH CAMINO ALTOTELEPHONE:
(707) 655-2264
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:6CENSUS: 4DATE:
09/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Evelyn SerranoTIME COMPLETED:
05:16 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with, Licensee, Evelyn Serrano. There are currently 4 residents in care. This facility is licensed for 6 non ambulatory residents, with hospice waiver approved for 2 of the residents and none of the residents are approved for bedridden.

LPA toured the home and found the home at a comfortable temperature with all exits free from obstruction. There are a total of four resident bedrooms, 4 staff/office bedrooms, 2 bathrooms, living room, dining room, kitchen and garage. Smoke detectors and carbon monoxide detectors were tested and operational. The fire extinguisher located in the front room and in kitchen was observed charged and facility had a proof of purchase of 8/31/2023. Fire drill was conducted by the facility and documented on 7/15/2023. The facility does not have any residents with Dementia diagnosis and facility does not require auditory alarms at this time. Water temperature in the resident bathroom was tested and found to be within appropriate range of 105-120 degrees. Bathrooms have required non-skid surfaces and grab bars. Cleaning products and knives are stored in a locked cabinets in the kitchen.

There was a 7 day supply of non-perishable foods. There are adequate dishes, glasses and silverware. Residents' medications are stored in the office. Resident and staff files are located and locked in cabinet in the office. LPA reviewed staff files and staff have the required training and proof of CPR/1st aid that expires 2025. Resident files were reviewed and found complete and organized.


Continue report see LIC809-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: JPS HOME CARE SERVICES
FACILITY NUMBER: 486803977
VISIT DATE: 09/15/2023
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Administrators certificate for Jocelyn Sebastian # 606175940 expires 9/1/2024. LPA requested facility to submit required paperwork to update the Administrator to :Jocelyn S. by 9/20/2023 to Community Care Licensing.


LPA discussed Emergency Disaster Plan and Infection Control Plan.

Licensee/Administrator to submit the current following documents by 10/10/2023:


· LIC 308 Designation of Facility Responsibility
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources
· LIC 610E Emergency Disaster Plan
· LIC 9020 Register of Facility Residents
Infection Control Plan of Operation (If changes)
Copy of Liability Insurance-



No citations issued during todays inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC809 (FAS) - (06/04)
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