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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803977
Report Date: 07/08/2024
Date Signed: 07/09/2024 10:46:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2024 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240606160922
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:
07/08/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Evelyn Serrano, LicenseeTIME COMPLETED:
04:34 PM
ALLEGATION(S):
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Facility is not meeting resident's needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced, for the purpose of continuing complaint investigation and delivering findings, regarding the above listed allegation.

LPA toured the home, took statements, made observations, reviewed records, and conducted a medication count for resident R1. It was alleged facility is not meeting residents needs and are also not able to handle R1's diagnoses of COPD. On 6/10/2024, LPA reviewed R1s medication records and reviewed medication. Investigation revealed there was several medication bottles that had too much medication and should have been finished if taken according to when the medication was picked up and physicians orders.

Continue report see LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20240606160922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/08/2024
NARRATIVE
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Continued report from LIC9099

Several medications were for helping and improving breathing problems and many of these medications were started but not finished and some had not been picked up for several months. Licensee expressed R1 refused to take medication several times and was also admitted at the hospital several times and that is why there was extra medicine. The facility had no proof or documentation on why there was extra medication.

Based on the above information the, Allegation, Facility is not meeting resident's needs, is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were observed (see LIC 9099D) and 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 and appeal of rights provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20240606160922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2024
Section Cited
CCR
87465(a)(4)
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87465(a)(4) Incidental Medical and Dental Care-A plan for incidental medical & dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.
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Facility to send in written plan on how they will ensure compliance for meeting residents needs and medication training. First POC due date for written plan due 7/9/2024, with follow up by 7/16/2024 for proof of medication training.
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This requirement was not met- As evidenced by: During medication audit of 6/10/2024 and today, the facility failed to properly provide some medication to R1. (Prednisone, Albuterol, Doxyclyne/antibiotic, verapamil)
This is an immediate risk to the Health & Safety of residents in care
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POC due to LPA Araceli Canela
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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: 07/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2024 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240606160922

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:
07/08/2024
ANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Evelyn Serrano, LicenseeTIME COMPLETED:
04:34 PM
ALLEGATION(S):
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Facility is not ensuring a comfortable temperature
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced, for the purpose of continuing complaint investigation and delivering findings, regarding the above listed allegation. LPA toured the home, took statements and made observations. It was alleged Facility is not ensuring a comfortable temperature. LPA conducted a visit on 6/10/2024 and today and on both days the home is at a comfortable temperature. Facility states they have several fans to use in the home & an electric/window air conditioning unit in the livingroom, but the home does not have central air conditioning. They try to maintain the home comfortable for all residents. Staff expressed all residents are comfortable except resident R1, who they have put 4 or more fans and R1 also has one hand held. Staff do not feel the room high in temperature, but it does get a little warmer in the late afternoon. LPA took statements from 3 other residents and they all expressed they were comfortable and the home is not hot or cold. LPA was not able to get a statement from R1 because they were not in the facility. Although the allegation may be valid, based on statements and document reviews, there is not a preponderance of evidence to prove or, disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED. No citations issued today.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4