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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397004273
Report Date: 06/27/2025
Date Signed: 07/01/2025 08:59:36 AM

Document Has Been Signed on 07/01/2025 08:59 AM - 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:J & M CARE HOMEFACILITY NUMBER:
397004273
ADMINISTRATOR/
DIRECTOR:		ARLYN DE LA CRUZFACILITY TYPE:
740
ADDRESS:5766 FRED RUSSO DRIVETELEPHONE:
(209) 915-3961
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 6CENSUS: 5DATE:
06/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Sandra Glover and Juanito De la CruzTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 06/27/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility on-call staff person, Sandra Glover, who was briefly interviewed at this time. This LPA requested that she go ahead and contact the facility designated Administrator, Arlyn De la Cruz, to inform her that CCL was present at this time for an annual visit.
This LPA was able to speak with the facility designated Administrator, Arlyn De la Cruz, on the phone and learned that she was at a personal engagement, funeral service, and would not be able to attend and be present for this annual visit at this time. She indicated that all authority was given to the caregiver, Sandra Glover, who was currently present to be able to sign and engage with this LPA at this time.
It was learned that the husband, Juanito De la Cruz, was out of the facility at this time due to a personal medical appointment and would be available later on once his appointment had been fulfilled.
Juanito De la Cruz did arrive later to this facility after this LPA had toured and was in the process of conducting the file review for this annual visit.
Current census was 5 residents. Tour of the facility was conducted.
Living area, dining area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient, in good repair, and able to meet the needs of the residents at this time.
Kitchen area was toured. Cabinets and drawers were opened and the contents were reviewed at this time. Items for preparing, cooking, and serving meals unto the residents were observed to be sufficient and in compliance at this time.
Cleaners and cleaning agents were observed to be locked and made inaccessible to the residents at this time.
Fire extinguisher, located hanging on the wall adjacent to the refrigerator, was observed to have been annually inspected on 12/13/2024 by the local fire extinguisher company, Jorgensen Fire, and was in
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: J & M CARE HOME
FACILITY NUMBER: 397004273
VISIT DATE: 06/27/2025
NARRATIVE
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compliance at this time.
Medication cabinets located in the kitchen area were observed to be locked and made inaccessible to the residents at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Food supply, and food storage units, were observed to be sufficient and able to meet the needs of the residents at this time. This facility was observed to have, on hand at all times, a sufficient supply of 2-day perishable and 7-day nonperishable food quantities at this time.
A tour of the facility bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the facility restrooms was conducted. Grab bars, non skid mats, and toiletries were observed to be sufficient and able to meet the needs of the residents at this time.
Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees at this time.
A review of the laundry room was conducted. Bleach, detergent, and all other laundry supplies were observed to be locked and made inaccessible to the residents at this time.
Garage area was toured. It was observed that this area was used mainly to store facility related items at this time.
Exterior grounds of this facility were toured. Facility perimeter fence, side gates, and all other exits were reviewed at this time.
Administrator certificate for the facility designated Administrator, Arlyn De la Cruz, was observed to be present with certificate number 7001834740 and set to expire on 11/24/2025.
A review of (3) facility personnel files was conducted and noted on the following LIC 859.
A review of (5) facility resident files was conducted and noted on the following LIC 858.
The following forms and documents were requested to be updated and submitted into CCL:
LIC 308
LIC 400
LIC 500
LIC 610
The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.
This facility was assessed a civil penalty in the amount of $500 on the following LIC 421 BG.
Appeal Rights were printed and a copy was given to the facility representative at this time. Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/01/2025 08:59 AM - It Cannot Be Edited


Created By: Charlie Yang On 06/27/2025 at 12:20 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 & M CARE HOME
FACILITY NUMBER: 397004273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)(B)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in [1] out of [3] facility personnel did not possess proper fingerprint clearance and association to this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2025
Plan of Correction
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The facility designated representative stated that all facility personnel records will be updated to contain all of the required forms and documents related to fingerprint clearance and association and submit proof of correction into CCL by the due date. Proof of correction will entail copies of the updated forms and documents for facility personnel fingerprint clearance and association along with a statement of correction.
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [2] out of [3] facility personnel did not possess current First aid training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2025
Plan of Correction
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The facility designated representative stated that all facility personnel records will be updated to contain all of the required forms and documents and submit proof of correction into CCL by the due date. Proof of correction will entail copies of the updated forms and documents for first aid training and certification along with a statement of correction.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2025 08:59 AM - It Cannot Be Edited


Created By: Charlie Yang On 06/27/2025 at 12:20 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 & M CARE HOME
FACILITY NUMBER: 397004273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in [1] out of [3] facility personnel was dispensing medications without any certified hours of required medication training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2025
Plan of Correction
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The facility designated representative stated that all facility personnel records will be updated to contain all of the required forms and documents and submit proof of correction into CCL by the due date. Proof of correction will entail copies of the updated forms and documents for facility personnel medication training along with a statement of correction.
Type A
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that incontinent odors were prevalent throughout this facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2025
Plan of Correction
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The facility designated representative stated that all facility residents will be changed and toileted on a regular basis and submit proof of correction into CCL by the due date. Proof of correction will entail copies of the updated forms and documents for facility residents' care plan with toileting schedules and incontinence care along with a statement of correction.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2025 08:59 AM - It Cannot Be Edited


Created By: Charlie Yang On 06/27/2025 at 12:20 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 & M CARE HOME
FACILITY NUMBER: 397004273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87628(a)
Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in [1] out of [5] facility residents was unable to administer and handle any of their medications, including administering injections to oneself, and had to rely on the facility staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2025
Plan of Correction
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The facility designated representative stated that an updated plan of care will be implemented to address the care needs, specifically for diabetes injection, for this resident and submit proof of correction into CCL by the due date. Proof of correction will entail copies of the updated forms and documents for facility resident care plan along with a statement of correction.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2025 08:59 AM - It Cannot Be Edited


Created By: Charlie Yang On 06/27/2025 at 12:20 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 & M CARE HOME
FACILITY NUMBER: 397004273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in [1] out of [3] facility personnel did not even have a file with all of the required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2025
Plan of Correction
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2
3
4
The facility designated representative stated that all facility personnel records will be updated to contain all of the required forms and documents and submit proof of correction into CCL by the due date. Proof of correction will entail copies of the updated forms and documents for facility personnel along with a statement of correction.
Type B
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in [2] out of [3] facility personnel records did not contain the required hours of initial and ongoing training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2025
Plan of Correction
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2
3
4
The facility designated representative stated that all facility personnel will be updated to obtain all of the required hours for initial and ongoing training, with certification, and submit proof of correction into CCL by the due date. Proof of correction will entail copies of the updated initial and ongoing training hours for all facility personnel along with a statement of correction.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Charlie Yang
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2025


LIC809 (FAS) - (06/04)
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