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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700633
Report Date: 12/03/2021
Date Signed: 12/03/2021 12:18:42 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/03/2021 12:18 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
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: 20DATE:
12/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Igmedio DiosoTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA ) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff (Dioso) and explained the purpose of the visit.

LPA 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 126.9 not within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA observed centrally stored medications are kept locked and inaccessible to residents. LPA reviewed and compared resident medication vs. resident medication logs. During the medication review LPA observed medication pre-poured for 5 days for R1.

LPA reviewed 2 resident and staff files, including criminal record clearances. All staff are Fingerprint cleared and associated to the facility. During the staff file review LPA observed expired first aid and CPR cards for 2 staff (S1 and S2).

First aid kit was checked and is complete. Fire drill was conducted on 5/2021

Deficiencies were observed pursuant to Title 22 rules and regulations, Health and Safety Codes.

Exit interview conducted report and appeal rights given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
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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Document Has Been Signed on 12/03/2021 12:18 PM - It Cannot Be Edited


Created By: Albert Johnson On 12/03/2021 at 11:17 AM
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
, 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: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2021
Section Cited
CCR
80088(e)(1)

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Furniture, Fixtures, Equipment, and Supplies
1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C)....
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Administrator lowered the thermostat during the tour and agreed to test the hot water for 3 days. Test hot water in the bathroom to meet Title 22 regulations. Send 3 day hot water temperature to LPA.
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LPA tested hot water at 126.9 degrees F. Licensee failed to assure hot water meeting Title 22 regulation of 105-120 degree F. This poses a potential health and safety risk to resident in care.
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Type B
12/10/2021
Section Cited
CCR80075(k)(5)

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80075(k)(5) Health Related Services. Each client's medication shall be stored in its originally received container. This requirement was not met as evidenced by observation, LPA and Staff observed pre-poured medication for R1. When asked by LPA,
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The Administrator shall submit a plan of how the facility will dispense medications to clients on daily basis. All facility staff who manage, store and dispense medication shall attend an in-service medication training.
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the Staff confirmed that they pour for seven days, because the medication come in bottles from outside agency. This posed a potential health and safety risk to resident’s in care.
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Training certificate shall be submitted to Licensing by, 12/10/21.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/03/2021 12:18 PM - It Cannot Be Edited


Created By: Albert Johnson On 12/03/2021 at 11:33 AM
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
, 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: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2021
Section Cited
CCR
85165(b)(2)

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Emergency Intervention Staff Training
Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training
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Licensee/Administrator shall ensure all staff have current first aid and CPR Certificates. By POC Date.
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and be certified for having successfully completed the training.

2 Staff have expired First Aid Certificates
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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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021


LIC809 (FAS) - (06/04)
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