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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700633
Report Date: 12/07/2022
Date Signed: 12/07/2022 10:30:42 AM

Document Has Been Signed on 12/07/2022 10:30 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, 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: 18DATE:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Consulita Fernando - Assistant AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA ) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA met with assistant administrator and explained the purpose of the visit.

LPA and assistant administrator toured and inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility.

LPA observed sufficient seven days non-perishable and two days perishable food supplies. Hot water temperature was measured at not within the required range of 105 to 120 degrees.

Fire extinguishers were last serviced on 11/22/2022 and smoke detectors are current and in compliance with fire safety. First aid kit was checked and is complete. Fire drill was last conducted on 8/5/2022. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs.

LPA reviewed three (3) resident and three (3) staff files, including criminal record clearances. All staff are Fingerprint cleared and associated to the facility. During the staff file review LPA observed all staff have current first aid and CPR cards.

No deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted and copy of report given to assistant administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Ruth Wallace
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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