079200340-10-9-2024-15-AS-CFOR-D9VT3Q-20241009142244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200340
Report Date: 10/09/2024
Date Signed: 10/09/2024 02:22:59 PM

Document Has Been Signed on 10/09/2024 02:22 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	JP'S CARE HOME		FACILITY NUMBER:	079200340
ADMINISTRATOR:	GWYNNE JUDAN		FACILITY TYPE:	740
ADDRESS:	1829 REDWOOD ROAD		TELEPHONE:	(510) 799-9424
CITY:	HERCULES	STATE: CA	ZIP CODE:	94547
CAPACITY:	6	CENSUS: 4	DATE:	10/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	MARILYN JUDAN, ADMINISTRATOR		TIME COMPLETED:	03:15 PM

NARRATIVE

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On 10/09/2024 at 9:45 AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct the Required Annual Inspection. Upon entry, LPA stated the purpose of the visit to Marilyn Judan, Administrator.

LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication cabinet located in the kitchen. Smoke detectors and carbon monoxide detectors were observed in working condition. Fire extinguishers were observed to be full and last serviced on 10/05/2024. Temperature in the facility was measured at 70.0 degrees Fahrenheit. Water temperature is 73.0 degrees Fahrenheit.

The LPA observed required postings in the facility, including the Complaint Poster, Ombudsman and Personal Rights posters, and the Theft and Loss Policy. An administrator is on site more than the minimum of 20 hours a week to oversee the proper business operations.

Grab bars for each toilet and shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. .

One week of nonperishable and 2 days of perishable food and water supplies were available.

Continue on LIC 809C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

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 10/09/2024 02:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JP'S CARE HOME	FACILITY NUMBER: 079200340
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(3)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having warter tempature 73 degrees F which poses a potential health and safety risk to persons in care.
	POC Due Date: 10/11/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have water heater turned up and take a video of the water tempature and submit to the department by the POC date.

Type B

Section Cited

CCR

87307(d)(4)

Personal Accommodations and Services

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having items on the open Porsche water machine, boxes, plastics, chairs, lamps, facility also has unlocked rake, 2 ladders, wheel barrow, wood planks with nails, shovel located in the back yard which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/05/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have items removed and to put the ladders, rakes and wheel barrow in the locked storage and submit photos to the Department by the POC date.

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/09/2024 02:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JP'S CARE HOME	FACILITY NUMBER: 079200340
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: 2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having allergy relief medication unlocked in a kitchen cabinet which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/10/2024
	Plan of Correction
1 2 3 4	Administrator agreed to keep all medication locked at all times, Administrator also agreed to conduct in-service with staff and submit sign in attendance sheet by the POC date. DEFICIENCY CLEARED DURING VISIT.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JP'S CARE HOME	FACILITY NUMBER: 079200340
	VISIT DATE: 10/09/2024

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continue from LIC809

LPA observed the following deficiencies:

· At 10:58am, LPA observed water machine, boxes, plastics, chairs, fruit, onions, and lamps located on the open porch.
· At 10:59am, LPA observed 2 rakes, 2 ladders, wheel barrow wood planks with nails, and shovel.
· At 11:15am, LPA observed unlocked allergy relief medication located in kitchen cabinet.

LPA requested the following documents to be submitted to CCLD by 10/16/2024.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the LIC421IM, this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC809 (FAS) - (06/04)

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