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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830758
Report Date: 05/24/2022
Date Signed: 05/24/2022 11:01:47 AM

Document Has Been Signed on 05/24/2022 11:01 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:JJ HOME 1FACILITY NUMBER:
486830758
ADMINISTRATOR:SANA, JOSEPHINEFACILITY TYPE:
740
ADDRESS:1004 YARKON CTTELEPHONE:
(707) 759-4573
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 4CENSUS: 4DATE:
05/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Josephine Sana, AdministratorTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Karina Canela arrived unannounced to conduct an Annual Required - 1 Year 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.
LPA conducted a tour with Lead DSP Mark of the facility which was observed clean and at a comfortable temperature. All exits were observed unobstructed. A screening station was observed at front entrance of facility which had hand sanitizer, a thermometer, and a sign-in sheet for visitors and staff. LPA was screened for COVID-19 symptoms and temperature was taken and documented. All visitors are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Staff verify visitor's vaccination status or a negative COVID test as required for indoor visitation.
The facility has designated visitation areas, provides virtual visits and phone calls for family to stay in contact with residents. Staff and resident's temperatures are taken daily and documented. Staff clean and disinfect the facility 3 times daily and LPA observed documentation of a cleaning/disinfection schedule. Staff have documented completion on the following training: infection prevention, symptoms, transmission and PPE use. The facility has an ample supply of PPE including gloves, face shields, N-95 respirators, surgical masks and disposable gowns. LPA observed COVID-19 precaution postings, liquid hand soap and paper towels available in bathrooms.
The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services, Community Care Licensing. LPA verified staff vaccination, all staff have completed and have documentation in their files.
N-95 Fit testing for staff has been completed (LPA observed N-95 Fit test documentation and test kit for all staff); . LPA observed 4 residents in care participating in activities.
All staff wore 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: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/24/2022
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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