486830758-5-23-2024-21-AS-JFLO-D5JSVC-20240523141228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486830758
Report Date: 05/22/2024
Date Signed: 05/23/2024 02:12:41 PM

Document Has Been Signed on 05/23/2024 02:12 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	JJ HOME 1		FACILITY NUMBER:	486830758
ADMINISTRATOR:	SANA, JOSEPHINE		FACILITY TYPE:	740
ADDRESS:	1004 YARKON CT		TELEPHONE:	(707) 759-4573
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	4	CENSUS: 4	DATE:	05/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Josephine Sana, Administrator		TIME COMPLETED:	03:15 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	At approximately 8:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Mark Cabugwas who was the only staff member present. LPA was informed that there are 4 clients in care and all were away at day program, which is Monday - Friday from 8:00 AM - 3:00 PM. Licensee/Administrator, Josephine Sana was contacted and arrived at approximately 8:50 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with 1 dementia client in care. Facility has an approved fire clearance and capacity for 4 non-ambulatory clients. At approximately 8:55 AM, LPA initiated a tour of the facility and observed the following: Facility is a one-story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed client showers with grab bars an non-slip mats as required. LPA observed a supply of clean linens, incontinent care products, and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Two cabinets in communal areas containing cleaning supplies and other items that could pose a risk were observed unlocked. Licensee removed the items immediately and placed them in a locked cabinet in the locked garage. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. There is outdoor space for activities. LPA observed toys, games, ipads for each resident, an activity schedule, musical instruments and other supplies for client activities. The facility is hardwired with automatic fire doors, which were tested and operational. Fire extinguisher was last serviced July 2023. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular monthly disaster drills, and the most recent drill was conducted April 2024. LPA observed the facility's infection control plan, first aid kit, emergency supply of water, PPE, and other emergency supplies. Licensee states facility has a back-up generator if one is needed. LPA reviewed facility's emergency disaster plan and plan of operation and informed Licensee that both need to be updated to make considerations for clients with dementia. Licensee updated the facility's emergency disaster plan during visit and submitted it to LPA. Continued on 809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: JJ HOME 1	FACILITY NUMBER: 486830758
	VISIT DATE: 05/22/2024

NARRATIVE

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At approximately 9:45 AM 5 staff files and 4 client files were reviewed. All staff have required CPR and First Aid training certificates. LPA observed 2 of 5 staff do not have the required LIC503 - Health Screening signed by a physician and 1 of 5 staff files had LIC501 - Job application missing the staff member's signature. LPA also observed 1 of 5 staff files deficient in both annual and dementia training hours. LPA observed 5 of 5 staff files contained all the remaining required documentation.

LPA reviewed 4 of 4 client files and observed 1 of 4 with their individual service plan not signed by the responsible party. LPA observed that 4 of 4 client files had all the remaining required documentation per regulation. Facility coordinates and takes the clients to their medical and dental appointments as needed. LPA reviewed medications and medication records which are maintained in compliance with regulation. LPA reviewed P&I monies and logs, which were organized and maintained according to regulation.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
Proof of Staff Training
Staff Health Screenings Signed by Physician
Signed Client ISP
LIC610D- Disaster Plan
Updated Plan of Operation to include Dementia Care

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted with Licensee whose signature on this document confirms receipt. This report was reviewed with Licensee and Appeal Rights were given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: JJ HOME 1	FACILITY NUMBER: 486830758
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(c)

Plan of Operation

(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by not updating the facility's Plan of Operation to include considerations for clients with dementia which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	LIcensee to sumit an updated Plan of Operation to include considerations for dementia clients to CCL by POC due date 06/21/2024.

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation record review, the licensee did not comply with the section cited above in 3 out of 5 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	Licensee to submit proof of signed LIC503 - Health Screening signed by a physician for 2 out of 5 staff members and an LIC501 - Job application signed for 1 out of 5 staff members by POC due date of 06/21/2024

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: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 02:12 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: JJ HOME 1	FACILITY NUMBER: 486830758
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 observation and record review, the licensee did not comply with the section cited above in 1 out of 5 staff training records reviewed which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/21/2024
	Plan of Correction
1 2 3 4	Licensee to submit proof of completion of 1 out 5 staff members' required annual and dementia training by POC due date of 06/21/2024.

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: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/23/2024 02:12 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: JJ HOME 1	FACILITY NUMBER: 486830758
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

(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 observation, the licensee did not comply with the section cited above in 2 instances where chemicals, cleaning solutions, or disinfectants where found in communal cabinets which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2024
	Plan of Correction
1 2 3 4	Licensee removed the items immediately and locked them in a cabiniet in the locaked garage. Licensee agrees to not store Disinfectants, cleaning solutions, poisons which could pose a danger if readily available to clients in unlocked communcal areas.

Type A

Section Cited

CCR

87705(j)

Care of Persons with Dementia 87705 (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 3 exits inspected which did not have the auditory signal operational, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2024
	Plan of Correction
1 2 3 4	LIcensee and staff were able to fix auditory device and 3 out 3 exits were observed operational prior to inspection exit interview.

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: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

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