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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700633
Report Date: 10/28/2025
Date Signed: 10/28/2025 02:16:34 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/28/2025 02:16 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: 19DATE:
10/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Consulita Fernando, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 10/28/2025, Licensing Program Analyst (LPA) Renee Campbell arrived to the community to conduct the required annual inspection. LPA Campbell met with Licensee, Consulita Fernando and explained the purpose of the visit.

The facility is licensed to serve 26 ambulatory adults, 18 to 59 years of age. Currently, there are 19 people residing in the community. It is a one story facility, consisting of two separate buildings. The main building has a porch and may house 16 residents and contains the kitchen, a locked medication cabinet, dining room, resident bedrooms and bathrooms, cleaning products and supplies. The secondary house may house 10 residents and contains two bathrooms. Currently, there are 6 residents living in the secondary house and one of the bathrooms is locked off while the floor tiles are replaced and the doorknob is repaired. Water was measured in the bathroom at 112 degrees Fahrenheit (F) which with the required range of 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Both buildings encircle a courtyard area where residents may sit in a shaded area.

Upon entry to the primary building, LPA Campbell observed residents in the dining room or in their rooms, socializing or watching tv. The secondary building was bare of furniture in the living room. In the primary and secondary building, LPA Campbell observed resident bedrooms and bathrooms with twin beds, closets, night stand, clothing storage, curtains for windows and ceiling lights.

NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 I
FACILITY NUMBER: 502700633
VISIT DATE: 10/28/2025
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 In the bathrooms, floors had been mopped and toilets were observed to be cleaned. While showers were functional, LPA Campbell observed a shower with stained walls and floors. LPA Campbell urged licensees to either replace the shower or find a way to remove the stain.

In the facility kitchen, LPA Campbell observed a pot of soup and pre-made turkey sandwiches that would be served at lunch. LPA Campbell then went through the kitchen backdoor to the backyard area. The small backyard is protected by a fence held closed by a latching chain mechanism that can be easily removed from inside the yard. The fence was leaning from a reported hit and run a year ago. Fire extinguishers were last inspected on 04/08/2025 and were fully charged.

Of the 6 staff, LPA Campbell reviewed 2 files and they were found to be complete. Of the 6 staff currently working in the facility, one caregiver (S1) was not associated to the facility and could not be added during the visit. Currently, there are 19 residents and LPA Campbell reviewed files for 2 of them. Files were complete. LPA Campbell consulted with staff and reminded Administrator Fernando to remove staff from Guardian who are no longer working for the community.

During the visit, LPA Campbell consulted with licensee Consulita "Dee" Fernando regarding the improvements made and areas to focus on in the future. LPA Campbell observed that the office had been painted and the area clean and free of obstructions. The licensee stated that the community planned to continue painting the rest of the facility walls and gradually replace floors in the residents rooms. LPA Campbell suggested they focus on replacing showers where needed, replace refrigerators and replace the back fence.

Based on today's inspection, per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited and noted on LIC 809D. Note that failure to correct any deficiencies will result in additional civil  penalties.


NAME OF LICENSING PROGRAM MANAGER: Lisa Rios
NAME OF LICENSING PROGRAM ANALYST: Renee Campbell
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2025 02:16 PM - It Cannot Be Edited


Created By: Renee Campbell On 10/28/2025 at 12:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BJK RESIDENTIAL CARE I
FACILITY NUMBER: 502700633

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2025
Section Cited
CCR
80065(i)(2)

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Personnel Requirements
(i) Prior to employment or initial presence in the facility, all employees... subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 80019(f) ...This requirement is not met as evidenced by:
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Administrator will: submit the procedure to ensure new employees are fingerprint cleared & associated to the facility in guardian, provide a statement of correction for 80065(i)(-3) that is emailed to LPA Campbell, Confirm that the facility will not allow S1 to return until the process is complete.
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Based on record reviews, it was learned that the facility allowed S1 who is not associated to the facility or association has not been been transferred from another licensed facility, to be present in the facility.
This poses an immediate health and safety risk for persons 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.
Lisa Rios
NAME OF LICENSING PROGRAM MANAGER:
Renee Campbell
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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