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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200976
Report Date: 11/16/2021
Date Signed: 11/16/2021 12:45:04 PM

Document Has Been Signed on 11/16/2021 12:45 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JANGA CARE HOMEFACILITY NUMBER:
079200976
ADMINISTRATOR:KOLLIE, COMFORT K.FACILITY TYPE:
740
ADDRESS:3601 GENTRYTOWN DRTELEPHONE:
(510) 677-3734
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 6CENSUS: 0DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Comfort Kollie, AdministratorTIME COMPLETED:
01:00 PM
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On 11/16/21 at 12:00PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an infection control annual inspection and explained the purpose of the visit with administrator (ADM). LPA observed no residents or staff at the home during visit.

LPA inspected the facility inside and outside. Facility has a mitigation plan in place dated 11/2020 to mitigate the spread of COVID-19. LPA discussed the completed mitigation plan (LIC 808) with ADM as well as COVID-19 infection control practices. One central entry point has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks and no touch temperature probe. COVID-19 signs were observed posted in the common hallway to promote handwashing, cough/sneeze etiquette and physical distancing.

ADM stated facility will document daily temperatures and COVID-19 symptom checks for staff and residents once they have residents. Pathways were observed to be free of obstruction and fire hazards.

Continued on next page LIC 809-C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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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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: JANGA CARE HOME
FACILITY NUMBER: 079200976
VISIT DATE: 11/16/2021
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A written Emergency/Disaster plan dated 11/2020 was posted near the living room area. Centrally stored medications were locked in the kitchen cabinets. Sharp objects were locked underneath the kitchen sink. Toxic chemicals were locked in the garage. Infection control designated leader is the administrator.

ADM stated they will have at least 7 days of nonperishable and 2 days of perishable foods once they are operational. Emergency food supplies were observed stored in the garage. Facility room temperature was maintained at 70 degrees Fahrenheit. Resident's bedrooms and bathrooms have COVID-19 signages. Fire extinguisher was observed fully charged. Smoke and Carbon monoxide detectors were operational.

Adequate supplies of PPE were also observed stored in the garage. Facility follows daily cleaning, sanitation of frequently touched common surfaces using Clorox and Lysol disinfectants. T

No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided to ADM.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
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