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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441040
Report Date: 11/12/2021
Date Signed: 11/12/2021 03:21:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JONES REST HOMEFACILITY NUMBER:
011441040
ADMINISTRATOR:CHARLES W DRAKEFACILITY TYPE:
740
ADDRESS:524 CALLAN AVENUETELEPHONE:
(510) 483-6200
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:31CENSUS: 17DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lisa Rodriguez Director of SNFTIME COMPLETED:
12:46 PM
NARRATIVE
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On 11/12/2021 at 12:30 pm, Licensing Program Analysts (LPAs) C. Fowler and L. Hall arrived unannounced to conduct an Infection Control Inspection. LPAs met with Director of SNF, Lisa Rodriguez and explained the purpose of the visit. Charles Drake Administrator arrived at 12:55pm.

Upon entry, LPA's temperature was not checked. LPA observed there was no screening station. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, rehabilitation center and backyard.

During record review, LPAs did not observed visitors log and temperature logs for residents or staff. LPAs observed facility has a copy of Mitigation Plan on file.

The following deficiencies were observed during the visit:

-At 1:19pm, LPAs observed a broken closet door.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
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 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JONES REST HOME
FACILITY NUMBER: 011441040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety to persons in care.
POC Due Date: 11/19/2021
Plan of Correction
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Administrator agreed to fix closet door located in cottage #3 and submit photo copy to CCLD by POC Date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2021
LIC809 (FAS) - (06/04)
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