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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700633
Report Date: 03/10/2022
Date Signed: 03/22/2022 02:41:28 PM

Document Has Been Signed on 03/22/2022 02:41 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:BJK RESIDENTIAL CARE IFACILITY NUMBER:
502700633
ADMINISTRATOR:FERNANDO, ROBERTFACILITY TYPE:
735
ADDRESS:656 PARADISE RDTELEPHONE:
(209) 522-1569
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 26CENSUS: 17DATE:
03/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Robert and Consulita FernandoTIME COMPLETED:
03:30 PM
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Unannounced case management visit made out to this facility on 03/10/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility Licensee/Administrators, Robert and Consulita Fernando, and were briefly interviewed.
Current census was 17 residents.
The purpose of this visit was to follow up on the LIC 624A that was submitted into CCL on 03/07/2022 for resident R1.
Brief history was discussed about this facility and the events leading up to the morning of 03/03/2022 and resident R1.
This LPA will wait for additional forms and documents regarding R1 from this facility as more information is made available.
The facility designated Administrator stated that any new information will be scanned and submitted into CCL for review by this LPA.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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