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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830758
Report Date: 05/18/2023
Date Signed: 05/18/2023 02:48:37 PM


Document Has Been Signed on 05/18/2023 02:48 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:JJ HOME 1FACILITY NUMBER:
486830758
ADMINISTRATOR:SANA, JOSEPHINEFACILITY TYPE:
740
ADDRESS:1004 YARKON CTTELEPHONE:
(707) 759-4573
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 4DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Josephine Sana, AdministratorTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Karina Canela arrived for the purpose of conducting a Required -1 Year inspection and met with Josephine Sana, Administrator. All residents were at their scheduled Day Program during time of visit.
LPA toured the facility, all exits were unobstructed. 2 of 2 fire extinguishers were charged and serviced 08/30/2022. There are 10 hardwired smoke combination carbon monoxide detectors, which were tested & observed operational. The facility has submitted their Infection Control Plan to the California Department of Social Services, Community Care Licensing Division.
The facility was found to be clean & at a comfortable temperature; screening station was observed at front entrance. LPA observed a supply of PPE, linens (bedding, towels, etc.), and cleaning solutions (observed locked & inaccessible). Liquid hand soap and paper towels are available in bathrooms. 4 of 4 resident bedrooms were fully furnished per regulation. Facility food supply was within regulation and accessible to residents. Medication was centrally stored and inaccessible to residents.

LPA requested the following updated forms to be submitted to Community Care Licensing by 06/19/2023:
· LIC 308 Designation of Facility Responsibility (1 person per form)
· LIC 500 Personnel Report
· LIC 400 Affidavit Regarding Client/Resident Cash Resources (indicate if not handling cash for residents)
· Copy of Surety Bond
· Copy of Liability Insurance
· LIC 610E Emergency Disaster Plan
· Copy of current Administrator's Certificate

Exit interview conducted with Administrator, whose signature on this document confirms receipt.
***No deficiencies cited during this inspection
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Karina CanelaTELEPHONE: 707-588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023
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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