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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803977
Report Date: 07/29/2025
Date Signed: 07/29/2025 03:14:43 PM

Document Has Been Signed on 07/29/2025 03:14 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:JPS HOME CARE SERVICESFACILITY NUMBER:
486803977
ADMINISTRATOR/
DIRECTOR:		JULLY CARTELFACILITY TYPE:
740
ADDRESS:441 NORTH CAMINO ALTOTELEPHONE:
(707) 655-2264
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 5DATE:
07/29/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Jully Cartel, Administrator
Evelyn Serrano, Licensee
Olivia Pangilinen, Caregiver		TIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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07/29/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 5 residents in care. Facility approved/cleared for 6 ambulatory, of which 6 may be non-ambulatory and a hospice waiver for 3. LPA met with Evelyn Serrano, Licensee and Jully Cartel, Administrator. Both Licensee and Administrator gave permission for Caregiver to sign report.

LPA and caregiver toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was found to be stored in a safe manner being labeled and dated.

All rooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care were measured at 126.8 and 123.0 falling out of regulation range of 105 to 120 degrees F (Deficiency Cited). Fire extinguishers were charged and last purchased 09/05/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Toxins, sharps and other items that could pose threat if available to residents were located under the kitchen sink and found to be secured. Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

LPA conducted a review of 5 resident records. All records had the required documentation. However, LPA observed 2 of the 5 residents to not have an updated medical assessment (Technical Violation). LPA spoke with caregiver about ensuring residents receive an annual visit with a medical professional once every 12 months.

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Anthony Loera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2025
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 4
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: JPS HOME CARE SERVICES
FACILITY NUMBER: 486803977
VISIT DATE: 07/29/2025
NARRATIVE
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 LPA conducted review of 4 staff records/training. Upon a review of staff records, LPA found 3 out of 4 staff to have required annual and initial training as well as current 1st Aid & CPR certification on file. LPA found 1 out of 4 staff to have missing 4 hours of dementia training. LPA spoke with staff about ensuring they complete the 8 hours of required dementia care training.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 08/29/2025:

LIC308- Designation of Responsibility
Updated Liability Insurance
Register of Facility Clients/Residents

Exit interview conducted with Caregiver and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Anthony Loera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2025 03:14 PM - It Cannot Be Edited


Created By: Anthony Loera On 07/29/2025 at 02:27 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: JPS HOME CARE SERVICES
FACILITY NUMBER: 486803977

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs and staff observation, the facility did not comply with the section cited above in 2 out of 2 bathroom sinks accessible to residents were measured above 120 degrees F (49 degree C) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2025
Plan of Correction
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Licensee/Administrator shall submit a 7 day water temperature log for both bathrooms accessible to residents showing water temperature is within regulation of 105 degree F to 120 degree F. Water log shall be submitted with pictures of thermotoer in running water with temperature visible. Water log to be submitted to CCL by Plan of Correction (POC) due date 08/08/2025.
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.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Anthony Loera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2025


LIC809 (FAS) - (06/04)
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