486803977-9-19-2024-21-AS-MCUA-D99SZK-20240919141916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803977
Report Date: 09/19/2024
Date Signed: 09/19/2024 02:19:34 PM

Document Has Been Signed on 09/19/2024 02:19 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:	09/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Evelyn Serrano (Licensee)		TIME COMPLETED:	02:34 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) M Cuadra arrived unannounced to conduct an annual required one year inspection, LPA was greeted by staff and Licensee, Evelyn Serrano arrived later. There are currently 5 residents in care. No residents receiving hospice services at the moment. Annual fees are current. Contact information was reviewed. Required postings were observed. LPA/staff toured the facility inside and outside observed the following: the facility was at comfortable temperature with all exits free from obstruction. Some window screens needs to be cleaned (technical advisory was issued). Bedrooms were furnished per regulation. Smoke detectors and carbon monoxide detectors were tested and operational. Fire extinguisher were observed charged and service as of 9/5/2024. Licensee told LPA that the facility have not conducted a disaster drill within the last quarter (technical violation was issued). At approximate 9:25am water temperature in the resident's restroom measured 127 and 134.4 f degrees, which is not within range of 105 to 120 F degrees. Bathrooms have required non-skid surfaces and grab bars. At approximate 9:35am during physical tour of the facility, LPA/Licensee observed 3 litter of liquid soap, spray bottle 32 oz of disinfectant, Clorox bleach 32 oz and other cleaning solution bottles and disinfectants located under the sink were unlocked and accessible to residents. Linens and paper products were available. There was a one week supply of non-perishable foods and two days of perishable foods. LPA/Licensee observed in the refrigerator food not labeled and stored per regulation (technical violation was issued). LPA did not observe any staff encouraging activities to residents in care (technical violation was issued). Per Licensee, the residents are regularly taken to the park, bingo or watch television. LPA/Licensee discussed the importance and requirement to offer and provide daily activities to residents in care. Licensee agreed to re assess their current activity calendar and upgrade it as needed. Medication and medication records were reviewed. Medication was locked. Continue on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

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: 09/19/2024

NARRATIVE

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Continues from LIC809...
At approximate 10am LPA initiated file review of five residents and three staff files. Two out of three staff (S1 & S2) do not an additional 20 training hours annually completed. All staff have proof of CPR/1st aid training. Four out of five resident's (R1, R2, R3 & R4) care plan was not reviewed within the last 12 months. All residents have current medical assessment. However, LPA/Licensee discussed the importance to have some of medical assessments updated regularly to ensure that resident's needs have not changed over time.

Upon review of administrator information it was revealed that the facility needs to submit a change of administrator to Jocelyn Sebastian #606175940 expires 9/1/2024. However, last annual conducted on 9/15/23 and a case management conducted on 6/10/24; LPA Canela have requested to the facility to submit required paperwork to update the Administrator by not later than 6/19/24, but the Licensee did not submit documentation requested by the Department. Per Licensee, current administrator Lolita P. is a backup administrator and they have an acting administrator Jocelyn Sebastian who is currently recovering from surgery. However, none of the administrator mentioned do have an active administrator certificate as of today yet. LPA reviewed the Department's active/pending lists and there are no evidence that they have submit required documentation. Licensee agreed to appoint a new administrator and send required documentation (LIC 215 Applicant Information, Administrator Resume, Administrator certificate, LIC 500 Personnel Report and LIC 501 Personnel Record) to the Department by not later than September 25, 2024.

Licensee agreed to submit the current following documents by 9/25/2024: LIC 308 Designation of Facility Responsibility, LIC 610E Emergency Disaster Plan (if there are any changes) and copy of Liability Insurance.

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. Appeal rights given. Exit interview conducted with Licensee and copy of this report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2024 02:19 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: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/Licensee observation the hot water measured 127 and 134.4 degrees Fahrenheit, which is not in compliance with regulation, the licensee did not comply with the section cited above which poses an immediate health, safety risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Licensee agreed to adjust water heater to ensure the hot water is monitored between 105 to 120 degrees Fahrenheit. Licensee will submit a plan on how the facility will ensure the hot water is maintained in compliance with regulation by POC due date.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licensee observation and interview, the licensee did not comply with the section cited above by having cleaning solutions and disinfectans available to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	Licensee will submit a written plan to CCL outlining their protocol to keep items that pose a risk to residents in care inaccessible no later than POC due date, 9/20/2024.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2024 02:19 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: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above by not having an active administrator certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2024
	Plan of Correction
1 2 3 4	Licensee agreed to appoint a new administrator and send required documentation (LIC 215 Applicant Information, Administrator Resume, LIC 500 Personnel Report and LIC 501 Personnel Record) to the Department by not later than September 25, 2024.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licensee Asst observation, interview and record review, the licensee did not comply with the section cited above in two out of three staff have not completed their additional 20 hours annually, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2024
	Plan of Correction
1 2 3 4	Licensee agreed to have all staff complete required 20 hours annual training. Licensee will submit a self-certification form (LIC9098) to CCL ensuring that staff have completed required annual training hours by POC due date.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/19/2024 02:19 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: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in four out of five residents (R1, R2, R3 & R4) needs an updated care plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/25/2024
	Plan of Correction
1 2 3 4	Licensee agreed to submit a LIC9098 self-certification form ensuring that resident's care plans have been updated per regulation to CCL by POC due date to clear the citation.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024

LIC809 (FAS) - (06/04)

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