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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800004
Report Date: 11/08/2022
Date Signed: 11/08/2022 03:25:30 PM

Document Has Been Signed on 11/08/2022 03:25 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:B&J STEPHANIEFACILITY NUMBER:
496800004
ADMINISTRATOR:ZHENG, JUN JIFACILITY TYPE:
735
ADDRESS:2430 SANTA CRUZ COURTTELEPHONE:
(707) 527-6709
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 4CENSUS: 3DATE:
11/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Jun Ji Zheng (Administrator)TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection – 1 yr. Infection Control inspection met with staff, Dongmei Graves. Licensee/Administrator Jun Ji Zheng arrived later.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that staff were wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms. Hand sanitizer are located through the facility. Facility has a bathroom that is kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least once a day. Facility has designated an outdoor area for visitation. Facility staff have been trained on PPE protocols, but have not yet been N-95 fit tested. Staff and residents are being monitored daily and facility does document daily screening results in a binder. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate of staff and residents. Clients do attend to Day program in average of two days per week. Facility has games and other activities for client use during off days. Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields, gowns and hand sanitizer. Facility has submitted their Covid Mitigation Plan, it was approved on 3/12/21 and submitted their Infection Control Plan for review. At approximate 1:38pm LPA/Administrator observed two out of two fire extinguisher was last serviced on July, 2021.

Licensee provided updates for the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E). Cash Affidavit for client cash resources (LIC400) and Surety Bond.



Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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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Document Has Been Signed on 11/08/2022 03:25 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/08/2022 at 02:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: B&J STEPHANIE
FACILITY NUMBER: 496800004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
80020 (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in 2 out of 2 fire extinguisher was not serviced since July 2021 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2022
Plan of Correction
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Administrator will contact the Fire Department to have fire extinguisher serviced. Administrator agreed to submit Proof of Correction (POC) that fire extinguisher have been serviced and charged by a fire extinguisher service company or the Fire Department. POC due date 11/9/2022
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022


LIC809 (FAS) - (06/04)
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