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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002947
Report Date: 12/17/2024
Date Signed: 12/17/2024 03:20:02 PM

Document Has Been Signed on 12/17/2024 03:20 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:J & H CARE HOMESFACILITY NUMBER:
345002947
ADMINISTRATOR/
DIRECTOR:		SALMAN, RASHAFACILITY TYPE:
740
ADDRESS:8529 ARROWROOT CIRCLETELEPHONE:
(916) 905-8038
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 6CENSUS: 4DATE:
12/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator Rasha SalmanTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 12/17/24 Licensing Program Analysts (LPAs) Cheyenne Ratajczak and Graham Gunby arrived unannounced to conduct a case management visit. LPAs met with Administrator Rasha Salman and explained the purpose of the visit.

The department has learned that staff 1 (S1) has been working and residing at this facility since April 2024. A review of S1’s criminal background clearance revealed that S1 was issued an order of exclusion by the department which was adopted on July 12, 2015. This order of exclusion states R1 is prohibited from employment in, presence in and contact with clients of, any facility licensed by the Department of Social Services for the remainder of S1’s life.

Effective immediately, S1 can no longer work, be present in this facility and should be removed from further staffing shifts.

Additionally, on 12/06/24 while S1 was working a shift R1 had left the facility unassisted and their whereabouts were unknown for about a hour and half. Administrator informed LPAs that S1 has not been working at the facility since 12/09/24.

The licensee shall submit to the department an updated staff schedule on 12/18/24 that indicates S1’s shifts will be covered.

The licensee has failed to obtain criminal record clearance for S1 therefore citations are being issued today as well as assessed civil penalties in the amount of $500.

Deficiencies cited, civil penalties assessed.



Exit interview and a copy of the report and appeal rights left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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 12/17/2024 03:20 PM - It Cannot Be Edited


Created By: Cheyenne Ratajczak On 12/17/2024 at 01:12 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: J & H CARE HOMES
FACILITY NUMBER: 345002947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/18/2024
Section Cited
CCR
87355(e)(1)

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87355(e)(1) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.
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Licensee stated that S1 has not been in the facility since 12/09/24. Licensee shall submit to the department an updated staff schedule on 12/18/24 that indicates S1’s shifts will be covered. Licensee will also submit a statement of understanding that all staff must be fingerprint cleared prior to wokring in the facility.
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Based on record review, the licensee did not comply with the section cited above due to caregiver not being fingerprint cleared which poses an immediate health and safety risk to persons in care.
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Type A
12/18/2024
Section Cited
CCR87411(a)

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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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Licensee is to submit a plan of how facility will ensure that staff know the general whereabouts of residents and plan a staff training.

POC to be emailed to LPA by POC due date.
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Based on file review and interview, the Licensee did not comply in the section cited above as R1 was observed to have left the facility and is unable to leave the facility unassisted which poses an immediate health and safety risk for 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:Laura Munoz
LICENSING EVALUATOR NAME:Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2024


LIC809 (FAS) - (06/04)
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