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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486830759
Report Date: 04/12/2024
Date Signed: 04/12/2024 03:41:11 PM

Document Has Been Signed on 04/12/2024 03:41 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:JJ HOME 2FACILITY NUMBER:
486830759
ADMINISTRATOR/
DIRECTOR:
SANA, JOSEPHINEFACILITY TYPE:
740
ADDRESS:449 DAWSON CREEK DRIVETELEPHONE:
(510) 331-9139
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 4CENSUS: 4DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Josephine Sana, Licensee TIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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On 4/12/2024, Licensing Program Analysts (LPAs) Mutialu and Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by staff, Conatel Garcia and Jesusan Icang. Administrator, Josephine Sana was contacted and arrived later in the visit. The facility is licensed for 4 non-ambulatory. The facility currently provides care for 4 residents, none of which are receiving hospice services or with a diagnosis of dementia..

LPAs continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility to be recently charged on 7/21/2023 at the time of visit. Smoke and carbon monoxide detectors are interconnected throughout the facility, were tested and found to be functioning. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate labeling. Staff provide residents with meals according to dietary restrictions with an ample amount of fresh and healthy foods observed.

Cleaning supplies and other toxins are safely stored in a locked cabinet in the laundry room and garage all of which were secured upon inspection. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in a kitchen drawer. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Water was measured at faucets accessible to residents and measured between 111.7 and 116.6 degrees F which is within regulation.

Continued onto LIC809-C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: JJ HOME 2
FACILITY NUMBER: 486830759
VISIT DATE: 04/12/2024
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Medications located in designated medication room in the hallway area and were found to be secured. LPAs conducted a spot check of medications and found all administering and records to be in order. Residents that were awake during the inspection were observed interacting with staff in the common area, in their bedroom watching television or visiting with family. The facility also offers regular family visits and gatherings as well as encouraging residents to exercise and increase their mobility. There is one emergency exit located in the backyard which was found to be unobstructed. There is an outdoor patio with outdoor umbrella providing shade and large outdoor space for residents to utilize with exits equipped with ramps for accessibility. The facility conducts emergency disaster drills and provided documentation to LPAs for review. LPAs observed driveway cement cracked and uneven in two locations leading from emergency exit path. Per Administrator and Brilliant Corners maintenance service person, request for repair has been submitted. Licensee agrees to provide update of repair completion. Technical Advisory issued.

LPAs conducted a sample file review for staff and found all staff to have appropriate annual training and 1st Aid & CPR certification on file. LPAs also conducted a file review for all residents. Upon review, LPAs found that all resident Needs & Service Plans and Physician's Reports to be current. LPAs recommended licensee to update resident (R!) Physicians Report. All required positing and signeage at the front and hallway of the facility were found to be in order with information easily accessible for staff and residents.

Administrators Josephine Sena's Administrator Certification 6013529740 is currently pending for renewal. Documentation of training and status on pending list provided to LPAs. Administrator Jennica Narciso's Administrator Certification 6018481740 is valid through 9/24/2024.

LPA requested the following documents be sent to CCL by COB 5/12/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
Control of Property/Rental Agreement

No deficiencies cited
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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