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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700633
Report Date: 12/04/2024
Date Signed: 12/04/2024 01:17:27 PM

Document Has Been Signed on 12/04/2024 01:17 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/
DIRECTOR:
FERNANDO, ROBERTFACILITY TYPE:
735
ADDRESS:656 PARADISE RDTELEPHONE:
(209) 522-1569
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 26CENSUS: 20DATE:
12/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Consulita Fernando, ManagerTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 12/04/2024, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility to conduct an annual inspection. LPA Campbell met with Consulita Fernando, Manager and explained the purpose of the visit.

The facility is a single story building with 13 bedrooms and 19 residents. No changes have been made to the floor plan of the building. All staff found on the facility roster have been verified as fingerprint cleared and are associated to the facility.

Upon entry, LPA Campbell conducted a tour of the facility with the Manager. Bedrooms were observed to have two residents per room and contained a bed, drawers, closets and lamps. The floors and walls of the staff area had been redone. Per the Manager, staff will be gradually redoing the floors and walls of the entire facility.. The facility was free of odor and no obstacles were observed in pathways.. The fire extinguishers were last inspected on 04/26/2024. Cleaning items were observed under lock and key in the closet near the dining room. There was enough perishables to last 2 days and enough non-perishables to last 7 days.

An Earthquake and Fire Drill log was reviewed. Dates and staff and client participants were listed monthly.. LPA Campbell provided a report template for future disaster drills. Of the 7 staff files available, LPA Campbell reviewed 6. One staff file was missing a health screening. Of the 20 residents, LPA Campbell reviewed 3 of the files and all were found be complete. During the file review, LPA Campbell suggested that hire dates for staff be added to the file tabs by the employees name to make the information easier to find.

The thermostat was set at 70 degrees Fahrenheit (F), which is within the required range of 68 and 85 degrees. Manager Fernando requested information on how to update the administrators name. LPA Campbell emailed the items requested. Exit interview conducted and a copy of the report provided.. No deficiency cited.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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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