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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830759
Report Date: 06/29/2021
Date Signed: 06/29/2021 11:28:29 AM

Document Has Been Signed on 06/29/2021 11:28 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:JJ HOME 2FACILITY NUMBER:
486830759
ADMINISTRATOR:SANA, JOSEPHINEFACILITY TYPE:
740
ADDRESS:449 DAWSON CREEK DRIVETELEPHONE:
(510) 331-9139
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Josephine SanaTIME COMPLETED:
11:40 AM
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Licensing Program Analysts (LPA), Farhaan Sarangi and Erik Gonzalez Campos arrived unannounced to conduct a Required 1 year inspection at approximately 10:00 AM, and met with administrator Josephine Sana. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPAs were greeted by staff and and asked to sign in after COVID symptom screening. At primary entrance LPAs observed temperature logs and visitor sign-in sheet. LPAs conducted walk through of the facility with S1. Administrator arrived later. LPAs observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL).

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Staff have completed Personal Protective Equipment (PPE) and infection control training through the Department of Public Health. Staff have not been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPAs confirmed administrator has necessary PPE equipment and supplies to support a resident in isolation.

Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked garage cabinet. A 30 day supply of medications are stored in a locked cabinet inside administrator's office making them inaccessible to residents. The facility has a sufficient supply of Personal Protective Equipment (PPE) and hygiene supplies. LPAs were shown binder where documentation of fire drills and smoke detector tests are kept, documentation was current. Facility is conducting COVID-19 surveillance testing per CCL guidelines.

Continued on LIC 809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 2
FACILITY NUMBER: 486830759
VISIT DATE: 06/29/2021
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. Upon examination of facility roster it was found one staff S2 was not associated. LPAs advised administrator to have S2 associated. LPAs observed backyard fence under remodel and requested notification through email to CCL.

LPAs requested the following documents:

LIC 309
LIC 400
LIC 500
LIC 402
Administrator Certificate


Administrator and LPAs discussed their Emergency Disaster Plan and confirmed it is current.

LPAs unable to print, will email report and supporting documentation to administrator

No deficiencies cited during this inspection
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC809 (FAS) - (06/04)
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