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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802021
Report Date: 03/14/2022
Date Signed: 03/14/2022 03:32:08 PM

Document Has Been Signed on 03/14/2022 03:32 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 CHARNING CROSSFACILITY NUMBER:
496802021
ADMINISTRATOR:ZHENG, JUN JIFACILITY TYPE:
735
ADDRESS:1008 CHARNING CROSS LANETELEPHONE:
(707) 546-4208
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 4DATE:
03/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jun Zheng (Administrator)TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee, Jun Zheng. LPA/Licensee reviewed PIN 22-05, PIN 22-06, PIN 22-07 and PIN 22-09.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA/Licensee observed that facility doesn't have Covid19 related posters on the front door. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/Licensee conducted a walk-through of the facility and observed hand washing signs. Hand sanitizer were observed in the common area of the facility. Facility bathrooms are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least twice a day. Facility is able to accommodate a single room for each resident that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols, but have not been N-95 fit tested. Staff and residents are being monitored daily and results are not documented. LPA/Licensee discussed the importance of daily screening and documentation of the results. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate and received boosters for staff and clients. Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Four clients do attend to day program three times per week and facility provides activities for clients at home. Clients receive indoor visitation with their families and facility has antigen tests to visitors as well as screening, documenting for symptoms and tracking purposes. Facility has submitted their Covid Mitigation Plan and approved on 3/12/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are located in an accessible place for staff.
Licensee agreed to provide updates of the following by 3/28/22: Administrative Organization (LIC309), Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), affidavit regarding client/resident cash resources (LIC400), Surety Bond and Emergency Disaster Plan (LIC610E). 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. ***Civil penalties are being assessed in the amount of $250 for repeated violation.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2022
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 03/14/2022 03:32 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 03/14/2022 at 02:34 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 CHARNING CROSS
FACILITY NUMBER: 496802021

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, interview and records review Licensee did not ensure that staff and clients are being monitored daily for symptoms of Covid19 and results documented as reflected in facility's mitigation plan and current CCL requirements. This poses an immediate risk to the health, safety and personal rights to the residents in care.
POC Due Date: 03/15/2022
Plan of Correction
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Licensee will ensure Personal Rights of residents are maintained. Licensee agrees to submit a written statement in how the facility will ensure to conduct daily screening and documentation of Covid19 symptoms for all staff and clients to CCL by 3/15/2022. ***Civil penalties are being assessed in the amount of $250 for repeated violation during visit conducted on 7/12/21.
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: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022


LIC809 (FAS) - (06/04)
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