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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200340
Report Date: 10/19/2022
Date Signed: 10/19/2022 02:14:18 PM


Document Has Been Signed on 10/19/2022 02:14 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 HOMEFACILITY NUMBER:
079200340
ADMINISTRATOR:GWYNNE JUDANFACILITY TYPE:
740
ADDRESS:1829 REDWOOD ROADTELEPHONE:
(510) 799-9424
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:6CENSUS: 5DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Lourdes Callejo, CaregiverTIME COMPLETED:
02:30 PM
NARRATIVE
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On 10/19/2022 at 12:15PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct Infection Control Inspection. LPA met with Caregiver, Edna Banagale and explained the purpose of the visit.
Administrator Marylyn Judan arrived at approximately 12:40pm

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. JPFacility has a mitigation plan and maintains record of routine screening for residents and staff.

The following deficiencies observed during the visit:

-At 12:20 pm, LPA observed gardening trimmers, 3 ladders, 3 rakes, wood planks, toilet pots, wheelchairs, wood, shovel, kingsford charcoal located in the backyard.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

Continue on LIC 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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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: 10/19/2022
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Continue from LIC 809


Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/27/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/19/2022 02:14 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: 10/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(1)(a)
(1) 87309 Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Storage areas for poisons... shall be locked.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation licensee did not comply with the section cited above by having gardening trimmers, ladders, rakes, wood planks, toilet pots, wheelchairs, shovel, kingsford charcoal accessible to residents which poses an immediate health and safety risk to persons in care
POC Due Date: 11/02/2022
Plan of Correction
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POC: Administrator agreed to remove the gardening trimmers, ladders, rakes, wood planks, toilet pots, wheelchairs, shovel, kingsford charcoal and submit photo to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
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