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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700633
Report Date: 10/12/2022
Date Signed: 10/12/2022 02:58:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/02/2022 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20220802144754
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:
10/12/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Consulita FernandoTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not keep the facility free of bugs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown and Dana Garcia, Associate Governmental Program Analyst (AGPA) arrived unannounced to conclude a complaint investigation on 10/12/22 at 11:00AM. The team met with Consulita Fernando, Assistant Administrator and stated the purpose of the visit. The team toured the facility physical plant inside and outside during this visit. The team also interviewed residents (R1-R7) and Consulita Fernando, Assistant Administrator during this visit. During the tour the team observed a random amount of rooms, furnishings, common areas and kitchen. The team did not observe any cats on the premises but there was cat food in resident #1's room. R1 admitted ownership of 1 cat that resides inside and outside of the faciity. R1-R7 all concur that they do not have bug or flea bites. The team observed several (type unknown but small in size) bugs on R2's bed and flies in the facility during this visit. Consulita Fernando, Assistant Administrator stated that there is a Orkin Pest Control contract in place and that there was a service conducted two weeks ago. However, the service does not include furniture and/or bedding checks.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20220802144754
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 I
FACILITY NUMBER: 502700633
VISIT DATE: 10/12/2022
NARRATIVE
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LPA requested and received a copy of the Orkin contract. A review of the contract revealed a monthly visit with a service conducted to the exterior perimeter of the facility since March 2022-September 2022.

The investigation revealed that R1 stated there are no bugs in the facility and has not sustained any bug bites.
The team observed movement of several bugs on the bedding (mattress) of R2 and no bites were observed on the skin.

Based on observation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 6, deficiencies are being cited on the attached 9099D during this visit.

If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20220802144754
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 I
FACILITY NUMBER: 502700633
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2022
Section Cited
CCR
80087(a)(1)
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Buildings and Grounds
The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
The licensee shall take measures to keep the facility free of flies and other insects.
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Administrator shall revise contract with orkin or secure a pest control to include inside the facility. Proof of completion to be sent to CCL by POC due date.
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This requirement is not met as evidenced by:
Administrator did not observe bugs inside the facility.
Based on observation of R2's bed and flies throughout the facility.
This violation poses a potential health, and safety risk to residents in care.
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3