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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830758
Report Date: 05/27/2021
Date Signed: 05/27/2021 12:13:12 PM

Document Has Been Signed on 05/27/2021 12:13 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:JJ HOME 1FACILITY NUMBER:
486830758
ADMINISTRATOR:SANA, JOSEPHINEFACILITY TYPE:
740
ADDRESS:1004 YARKON CTTELEPHONE:
(510) 331-9139
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Josephine Sana, Administrator TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required inspection and met with Josephine Sana, Administrator. The annual inspection is focused on the Infection Control procedures and practices of this Residential Care Facility for the Elderly.
Upon arrival, LPA observed a screening station at the entrance of facility which had hand sanitizer, a thermometer, and a sign-in sheet for visitors and a separate sign-in sheet for staff. Administrator took LPA's temperature, documented LPA's name and asked the facility's COVID-19 screening questionnaire at the front entrance. Staff and visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Resident's temperatures are checked twice a day, as well as their oxygen levels and screening for symptoms. LPA conducted a walk-through of the facility with Administrator and observed COVID-19 precaution postings. Staff clean and disinfect the facility daily during every shift. LPA observed documentation of cleaning and disinfection schedule. The facility has a designated visitation area, provides virtual visits and phone calls for family to stay in contact with residents. Administrator confirmed 90% of staff are surveillance tested for COVID-19 weekly; LPA observed copies of surveillance test results in a facility binder. LPA observed 4 residents in care, who were participating in activities and getting ready for lunch. Facility staff have completed PPE training and N-95 respirator Fit testing is in process.
LPA observed an ample supply of PPE including gloves, face shields, goggles, N-95 respirators, surgical masks and gowns. LPA observed plastic drawer space with PPE for all/each staff and plastic containers with PPE for each resident as a precaution for possible outbreaks. All staff wore face masks during this visit.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.



No deficiencies cited during this inspection
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2021
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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