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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700633
Report Date: 11/03/2023
Date Signed: 11/03/2023 02:05:17 PM

Document Has Been Signed on 11/03/2023 02:05 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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: 19DATE:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Celerina Belen, House ManagerTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA ) Renee Campbell conducted an unannounced Required 1 Year Annual Inspection Visit. LPA met with Celerina Belen, Caregiver and explained the purpose of the visit.
LPA and Caregiver 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 Campbell observed See Something Say Something poster, Facility Sketches and the signed Designated Facility Responsibility form in the facility.

LPA Campbell observed sufficient seven days non-perishable and two days perishable food supplies in the three refrigerators found in the main and supplementary kitchen. Hot water temperature was measured at 100 degrees Fahrenheit and was not within the required range of 105 to 120 degrees but may vary due to recent resident usage as they showered for the day.

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 10/11/2023. LPA observed centrally stored medications are kept locked and inaccessible to residents.

LPA reviewed two (2) resident and two (2) staff files. All staff are Fingerprint cleared and associated to the facility. During the staff file review LPA obseved that all staff were trained in CPR.
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 Caregiver, Celerina Belen.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
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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