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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547209037
Report Date: 05/26/2022
Date Signed: 05/26/2022 04:45:54 PM

Document Has Been Signed on 05/26/2022 04:45 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:J&M HOMEFACILITY NUMBER:
547209037
ADMINISTRATOR:SANDOVAL, JAREDFACILITY TYPE:
735
ADDRESS:616 W LOYOLA AVETELEPHONE:
(559) 409-2803
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY: 4CENSUS: 4DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Administrator Jared Sandoval via telephone and Staff Evelyn Salas. TIME COMPLETED:
05:00 PM
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On 05/26/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with staff Evelyn Salas. Administrator Jared Sandoval was called and unable to attend inspection. Administrator authorized staff to received report. LPA conducted a facility tour with staff. There are three clients present during tour.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was not observed upon entry. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility. LPA checked clients’ locked medications. 30 day PPE supplies was not observed. Food supply was checked and appeared to be adequate supply. At 2:58 p.m., LPA and staff observed fire extinguisher served date: 05/22/2020.

All clients’ room toured and observed to be adequately furnished and lit. LPA observed two bedrooms that are single occupant and one shared client’s bed to be at least 6 feet apart. All bathrooms observed trash bin with no lid. LPA observed hand washing posting by one of three sinks. Cleaning supplies were stored and unlocked in laundry room. At 3:26 p.m., LPA and staff observed garden tools and tools in garage unlocked. The exterior tour was conducted. Side gate was self-closing and self-latching. All clients’ records reviewed to have updated emergency contact information.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 06/03/22. The following updated forms were requested: Lic 308, Lic 309, Lic 400, Lic 402, Lic 500, Lic 610D, Lic 9020, and current Administrator certificate. Copy of this report and appeal rights was provided to staff and Administrator via email.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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 05/26/2022 04:45 PM - It Cannot Be Edited


Created By: Mai Yang On 05/26/2022 at 04:42 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: J&M HOME
FACILITY NUMBER: 547209037

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85064(f)

85064 Administrator Qualifications and Duties (f) When the administrator is … responsible and accountable for, management and administration of the facility in compliance with applicable law and regulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Fire Extinguisher has a service date of 05/22/2020, which poses an immediate health and safety risk to the residents.
POC Due Date: 05/27/2022
Plan of Correction
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Administrator states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 05/27/22.
Type A
Section Cited
CCR
80087(g)
80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA and staff observed multiple bottles cleaning chemicals stored inside an unlocked cabinet in the laundry room. LPA and staff observed gardening tools and toolset in the garage accessible to clients in care this poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/27/2022
Plan of Correction
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Administrator shall have cleaning chemicals, gardening tools and toolset stored in a locked area not accessible to clients in care. Administrator shall submit proof of POC to CCL office by 05/27/22.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
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