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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800004
Report Date: 10/24/2023
Date Signed: 10/24/2023 02:58:23 PM

Document Has Been Signed on 10/24/2023 02:58 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: 4DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Jun Zheng (Licensee)TIME COMPLETED:
03:13 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Required Annual Inspection and met with Licensee/Administrator Jun Zheng. Clients were attending to day program.

LPA initiated a tour of the facility at 12:15 pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client's bathroom measured at 117.8 and 119.7 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored in a locked cabinet located in living room. Toxins were locked in a closet located in the hallway. Knives were in a locked box located in the kitchen. Fire extinguisher was last inspected 11/2022. Smoke detectors located throughout the facility were tested and operational. Carbon monoxide detector was tested and operational. Licensee was unable to provide proof of last disaster drill conducted within the last quarter. Clients handle their own cash and have bank accounts. Outstanding annual fees are pending for this facility. On 9/22/23 LPA sent an outstanding email to Licensee to pay fees, but they are still pending as of today. Menu/activities reviewed.

File review was initiated at 1:00pm. 4 residents and 3 staff files were reviewed. However, one out of four resident's individual personalized plan have not been updated within the last 12 months. Four out of four clients file didn't have medical assessment on file. Per Licensee, all resident's medical assessments are in their other facility. Three staff files were reviewed. Three out of three staff files didn't have training hours on file, but their CPR/1st aid were current. Administrator Certificate for Licensee Jun Zheng 6030306735 expired on 1/8/23. However, Administrator provided proof that their administrator certificate is still pending in the system. Required postings were observed. Licensee to submit updates of the following documents by 11/1/23: Designation of Administrative Responsibility (LIC308), surety bond & Personnel Report (LIC500).
Deficiencies cited from the California Code of Regulations, Title 22. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 10/24/2023 02:58 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/24/2023 at 02:18 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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80065(a)
Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, records review and interview with the licensee, the licensee did not comply with the section cited above in 3 out of 3 staff have not received annual required training hours within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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Licensee agreed to provide self-certification LIC9098 notifying the Department that all staff have received annual contiunation required training hours by POC due date 11/1/23
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, records review and interview with the licensee, the licensee did not comply with the section cited above in 1 out of 4 resident's care plan has not been updated within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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Licensee agreed to provide self-certification LIC9098 notifying the Department that all clients have their care plans updated by POC due date 11/1/23
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: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/24/2023 02:58 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/24/2023 at 02:18 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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's bservation, records review and interview with licensee, the licensee did not comply with the section cited above in 4 out of 4 client's files did not have their medical assessment on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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Licensee agreed to provide self-certification LIC9098 notifying the Department that all client's medical assessments were brought back to the facility and are in their file by POC due date 11/1/23.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, records review and interview with the licensee, the licensee did not comply with the section cited above in conducting a disaster drill within the last quarter, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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Licensee agreed to provide proof that a current disaster drill have been conducted to clear the deficiency by POC due date 11/1/23
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: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/24/2023 02:58 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/24/2023 at 02:20 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: 10/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80036(c)(2)(e)

80036 (c)(2)(e) Licensing Fees. The failure of an applicant or licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license.” Licensee/Administrator has outstanding annual fees/late fees that are overdue-total owed is listed as $454.00. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, records review and interview with Licensee, The Department had notified Licensee in writing date 9/22/23 regarding the annual fees due including late fees accrued. Licensing Agency received no response. Licensee stated that he will submit a payment to Licensing department, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2023
Plan of Correction
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Licensee/Administrator to submit proof of payments made or when completing payment to Department of Social Services for the outstanding required fees by POC due date 11/1/23.
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: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2023


LIC809 (FAS) - (06/04)
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