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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200970
Report Date: 04/11/2024
Date Signed: 04/11/2024 02:21:30 PM


Document Has Been Signed on 04/11/2024 02:21 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:J AND R HOME CARE LLCFACILITY NUMBER:
079200970
ADMINISTRATOR:BISAHA, JOYFACILITY TYPE:
740
ADDRESS:1206 DAINTY AVETELEPHONE:
(925) 895-0756
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:10CENSUS: 0DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Joy Bisaha AdministratorTIME COMPLETED:
02:27 PM
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On 04/11/2024 At 11:20AM, Licensing Program Analyst (LPA) T.Syess-Gibson arrived to conducted an unannounced 1-Year Required inspection. At 11:21 AM LPA called the contact number from Licensing Information System (LIS) printout and spoke with Rene Tang contacted the Administrator via phone to advise of visit. At 11:48 AM Administrator Joy Bisaha arrived, LPA advised purpose of visit. Administrator currently holds an Administrator Certificate (#6030814740) which expires on 10/17/2024. The facility’s fire clearance was approved for Ten (10) non-ambulatory residents.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and three (3) bathrooms. All outdoor and indoor passageways are kept free of obstruction. LPA did not observe any bodies of water. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and no skid mats .There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was purchased on 04/28/2023. Emergency Disaster Plan was last posted on. First aid kit was observed to be complete. Fire drill will be conducted when residents move in..

Continued on LIC809C.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: J AND R HOME CARE LLC
FACILITY NUMBER: 079200970
VISIT DATE: 04/11/2024
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Continued from LIC809


LPA reviewed two (2) staff files which are current and complete. No residents files were reviewed, facility doesn't have any residents at this time.

LPA informed Administrator to contact CCLD when first resident moves in.

No deficiencies observed during visit.

LPA requested the following documents to be submitted to CCLD by 04/18/2024.

  • LIC 308 Designation of Administrative Responsibility
  • LIC 309 Administrative Organization
  • LIC 500 Personnel Report
  • LIC 610E Emergency Disaster Plan
  • Liability Insurance
  • LIC 200 and updated Facility Sketch


Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Tonica Syess-GibsonTELEPHONE: (510) 414-0641
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2