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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801888
Report Date: 08/13/2025
Date Signed: 08/13/2025 02:41:13 PM

Document Has Been Signed on 08/13/2025 02:41 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:JENSTEPH HOME CAREFACILITY NUMBER:
486801888
ADMINISTRATOR/
DIRECTOR:		AQUINO, RAFAEL V.FACILITY TYPE:
740
ADDRESS:736 ANITA CIR.TELEPHONE:
(707) 747-6659
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY: 6CENSUS: 5DATE:
08/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Rose Aquino-Licensee & Rafael Aquino-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 8/13/25 at approximately 10:25am, and met with Licensee Rose Aquino, and Administrator Rafael Aquino. There currently are five (5) residents in care. LPA observed two caregivers on duty upon admission into the facility.

Fire clearance approval is for six (6) non-ambulatory residents, there is no bedridden approval. Facility has an approved hospice waiver for one (1). Facility has an approved dementia plan of operation. Facility has a required infection control plan. Facility has an emergency disaster plan as required.

LPA reviewed five (5) resident files. Files were complete.

LPA reviewed four (4) staff files. All staff had required criminal record clearance. Staff had required first aid certification and CPR certification, per file reviews.

LPA toured the facility with Administrator Rafael. Facility was observed to clean and orderly. All postings were visible to all entering facility. Hot water was measured at 113. degrees Fahrenheit. All bathrooms had grab bars, and shower mats/non-slip flooring for resident use. Fire extinguisher was serviced and tagged as required. All exits were clear and free from obstruction. The bathrooms, resident rooms, hallways, and all common areas had sufficient lighting for residents' in care, and for use by residents. Facility had sufficient furnishings for resident use.Backyard was free and clear of any hazards, and backyard fire exit path was clear and free of obstruction. The backyard had patio furniture for residents' use. Exit doors had auditory alarms. Food supply was sufficient. Facility had sufficient supply of cleaners, paper products, linens. and personal protective equipment (PPE).

Continued on LIC809C..
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2025
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 5
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: JENSTEPH HOME CARE
FACILITY NUMBER: 486801888
VISIT DATE: 08/13/2025
NARRATIVE
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Continued from LIC809, dated 8/13/2025...

LPA requested the following documents be updated and submitted to CCL by 9/13/2025:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610 (9 pages) - Emergency Disaster Plan- if updates, submit copy to CCL
Infection Control Plan- if updates, submit copy to CCL
Copy of LIC400 Handling of Client Cash Resources- complete & submit (all facilities complete form)
Copy of Surety Bond- if handling cash
Copy of Current Liability Insurance
Roster of residents
Copy of current Administrator Certificate

Deficiencies observed by the LPA during inspection.
Staff S3 and S4, who are direct caregivers, lacked proof of required annual training, per file reviews. This deficiency will be cited, HSC 1569.625(b)(2) Staff training; legislative findings; contents - In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training, see LIC809D.

Staff S3 and S4, who assist residents with medications, lacked proof of required medication training, per file reviews. This deficiency will be cited, HSC 1569.69 (b) -Employees assisting residents with self-administration of medication; training requirements. Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator Rafael Aquino.
Appeal Rights provided to the Administrator.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2025 02:41 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/13/2025 at 02:03 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: JENSTEPH HOME CARE
FACILITY NUMBER: 486801888

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.69(b)
HSC 1569.69 (b) -Employees assisting residents with self-administration of medication; training requirements. Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA review of records, there was no proof of staff, S3 and S4, having obtained required annual medication training, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2025
Plan of Correction
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Licensee/Administrator to ensure that staff S3 and S4 obtain medication training as required by HSC 1569.69. Submit plan of correction by 8/14/2025, and follow-up with proof of training by 8/18/25.
POC due 8/14/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2025 02:41 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/13/2025 at 02:06 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: JENSTEPH HOME CARE
FACILITY NUMBER: 486801888

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
HSC 1569.625(b)(2) Staff training; legislative findings; contents - In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per LPA review of records, there was no proof of direct care staff, S3 and S4, having obtained required annual staff training, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2025
Plan of Correction
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Licensee to ensure that staff S3 and S4 obtain required annual training for direct care staff. Licensee to submit proof of staffs' annual training by POC due date of 9/325.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2025


LIC809 (FAS) - (06/04)
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