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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502700633
Report Date: 11/03/2023
Date Signed: 11/09/2023 08:42:24 AM

Document Has Been Signed on 11/09/2023 08:42 AM - 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Celerina Belen, CaregiverTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Renee Campbell conducted an unannounced case management visit to the facility on 11/03/23 to follow up on an incident that occurred on 10/16/23. LPA Campbell met with Celerina Belen, Caregiver and explained the purpose of the visit.

LPA Campbell reviewed a special incident report stating that R1 and R2 were involved in an altercation on 10/16/23, a Monday. The incident report was sent to licensing on 10/19/23, on Thursday. R2 had to be treated at the hospital for a laceration on his head before returning to the facility the next morning. Both residents apologized to each other with no further action taken.

LPA Campbell discussed with caregiver that reporting requirements are required for incidents that involve an injury which requires medical treatment. Incident Reports must then be submitted to licensing by the next business day.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Facility Designee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.

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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Document Has Been Signed on 11/09/2023 08:42 AM - It Cannot Be Edited


Created By: Renee Campbell On 11/03/2023 at 02:14 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: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2023
Section Cited
CCR
8006(1)(b)(D)

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Reporting requirement: Upon the occurrence, during .. operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the ... next working day...Any injury ... which requires medical treatment. This requirement was not met as evidenced by:
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Administrator agrees to read regulation 8006(1)(b)(D) and submit a signed declaration of understanding by POC date 11/07/23 and email it to renee.campbell@dss.ca.gov.
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Based on the document review received by licensing, the licensee did not submit the report by the next working day. This poses a potential a potential health, safety or personal rights 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.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023


LIC809 (FAS) - (06/04)
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