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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200340
Report Date: 09/09/2021
Date Signed: 09/09/2021 03:57:01 PM

Document Has Been Signed on 09/09/2021 03:57 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: 3DATE:
09/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Gwynne Judan, LicenseeTIME COMPLETED:
04:10 PM
NARRATIVE
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On 9/9/2021 at 2:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management inspection in regards to incident report received on 9/1/2021. LPA met with staff, Edna Banagale. Licensee, Gwynne Judan arrived 30 minutes later.

Incident report dated 9/1/2021 revealed that R1 was found missing. Before staff notify local law enforcement, police officers was at the front door bring R1 back to the facility.

Interview with S2 revealed residents are checked every 2 hours during night shift. When S2 check residents at 4:30AM, all residents were still in their rooms. However, when S2 check residents at 6:30AM, R1 was missing and S2 informed S3 to call the police. S3 spoke with police and was informed that R1 was with police officer. R1 and police officer was at the facility within 10 minutes. S1 stated that the alarm system was defective on the day of the incident and a new alarm system was purchased/installed on the same day of the incident

During record review, LPA observed that physician's report dated 4/18/2019 stated that R1 cannot leave the facility unassisted.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalty.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2021
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 09/09/2021 03:57 PM - It Cannot Be Edited


Created By: Grace Luk On 09/09/2021 at 02:51 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JP'S CARE HOME
FACILITY NUMBER: 079200340

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/10/2021
Section Cited
CCR
87303(a)

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Maintenance and Operation.
The facility shall be clean, safe, sanitary and in good repair at all times....
This requirement is not met as evidence by:
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A new alarm system was purchased on the day of the incident and LPA observed that the system is in operating condition during inspection.

Deficiency cleared during inspection
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Based on observation, licensee did not comply with the section cited above by having an inoperable alarm system which poses an immediate health and safety risk to the residents in care.
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Type B
09/30/2021
Section Cited
CCR87705(c)(5)

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Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment...done at least annually... This requirement is not met as evidence by:
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Administrator has agreed to obtain a current medical assessment for R1 and submit a copy to CCLD by POC date.
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Based on observation, licensee did not comply with the section cited above by not having an updated medical assessment for R1 which poses a potential health and safety risk to the 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:Harpreet Humpal
LICENSING EVALUATOR NAME:Grace Luk
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2021


LIC809 (FAS) - (06/04)
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