486830759-5-5-2023-21-AS-DTOA-CRJSJZ-20230505135556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486830759
Report Date: 05/05/2023
Date Signed: 05/05/2023 01:56:07 PM

Document Has Been Signed on 05/05/2023 01:56 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	JJ HOME 2		FACILITY NUMBER:	486830759
ADMINISTRATOR:	SANA, JOSEPHINE		FACILITY TYPE:	740
ADDRESS:	449 DAWSON CREEK DRIVE		TELEPHONE:	(510) 331-9139
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY: 4		CENSUS: 4	DATE:	05/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:46 AM
MET WITH:	Josephine Sana, Administrator		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/5/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by Lead Staff, Susan Icang. Administrator, Josephine Sana was contacted and arrived later in the visit. The facility currently provides care for 4 residents, 2 of which were attending day program at the time of visit. In addition, 4 residents are considered non-ambulatory and none of which are diagnosed with dementia. LPA arrived at the and continued with a tour of the facility with Lead Staff. Facility was at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found in the kitchen and hallway and to be last charged on 8/30/2022. Smoke and carbon monoxide detectors were interconnected, tested and found to be in working order. There was a sufficient supply of perishable and non-perishable foods as required by Title 22 Regulations, with staff meeting resident specialized dietary needs. All resident bedrooms have appropriate lighting and furniture with a supply of extra blankets and linens available. LPA conducted a sample review of staff training and found all staff to have sufficient number of hours required for annual training. In addition, LPA found that all staff have current CPR and 1st Aid certification on file. Toxins are stored in a locked garage and under the kitchen sink. Sharps are also secured in a designated drawer located in the kitchen. Water at faucets accessible to residents measured between 113.7 and 115.1 degrees F which is within Title 22 Regulations between 105 and 120 degrees F. Emergency Disaster Drills are conducted on a monthly basis with facility Emergency Disaster Plan posted at the front of the facility. Continued onto LIC809-C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 2	FACILITY NUMBER: 486830759
	VISIT DATE: 05/05/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA conducted a review of all resident files and found all records to be current. Upon review, LPA found that resident (R1's) Physician's Report indicated a bedridden status. However, R1 was attending day program at the time of visit and based on R1's level of care may be considered non-ambulatory. LPA and administrator discussed records to be reviewed and updated. Administrator contacted R1's Physician to review and update the ambulatory status. Administrator agrees to provide updated documents to LPA for review. Technical was issued to follow up on resident status.

Medications and facility records are stored in a secured medication room/office located in the hallway and inaccessible to residents. A spot medication and narcotic count was conducted and found to be in order. Staff follow proper medication recording, admission and destruction protocols with prescribed medications all delivered directly to the facility. The facility is in charge of resident P&I monies and upon review LPA found recorded amounts to be properly reconciled, secured and not commingled.

Administrator Josephine Sana's Administrator Certification 6013529740 is currently active until 2/21/2024.

Infection Control:
Facility holds records of vaccination status for all residents and staff. Posters have been placed throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature on daily basis or based on change of condition and are recorded.

No deficiencies cited during today's visit.

LPA requested the following documents be sent to CCL by COB 5/12/2023:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Liability Insurance

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2