<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800004
Report Date: 11/05/2024
Date Signed: 11/05/2024 10:41:24 AM

Document Has Been Signed on 11/05/2024 10:41 AM - 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/
DIRECTOR:		XIANGZHONG,FANFACILITY TYPE:
735
ADDRESS:2430 SANTA CRUZ COURTTELEPHONE:
(707) 791-7391
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 4CENSUS: 3DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:58 AM
MET WITH:Bing Wu (Licensee)TIME VISIT/
INSPECTION COMPLETED:
10:56 AM
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), Cuadra arrived unannounced to conduct a Required Annual Inspection and met with Licensee, Bing Wu. Annual fees are current. Contact information was reviewed. On October 31, 2024 the licensee submitted a change of ownership after Co-licensee passed away.

LPA/Licensee initiated a tour of the facility at 9:05 am 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 122.2 and 123.1 degrees F which are not 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. Required postings were observed. Fire extinguisher was last inspected November 8, 2023. Smoke detectors and carbon monoxide located throughout the facility were tested and operational. Last disaster drill was conducted on September 1, 2024. Cash resources were reviewed.

File review was initiated at 9:30 am, three client files and two staff files were reviewed. Client files has current care plans. However, two out of three clients didn't have medical assessment on file. Per Licensee, they will obtain a medical assessment for both clients (Technical violation was issued). Staff have required CPR/1st aid certificates and training hours per regulation. Administrator Certificate for Administrator Xiangzhong Fan # 7012046735 expires on 6/6/26. Medication and medication records were reviewed. Licensee to submit updates of the following documents by 11/12/24: Surety Bond.

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 was conducted with Licensee and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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 3
Document Has Been Signed on 11/05/2024 10:41 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/05/2024 at 10:34 AM
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: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 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 122.2 and 123.1 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: 11/12/2024
Plan of Correction
1
2
3
4
Licensee adjusted water heater to ensure the hot water is monitored between 105 to 120 degrees Fahrenheit. Licensee will keep a log of water temperature for 7 days and will send the log to CCL ensuring that hot water is maintained in compliance with regulation by POC due date.
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
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3