<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011441040
Report Date: 11/14/2024
Date Signed: 11/14/2024 03:14:11 PM

Document Has Been Signed on 11/14/2024 03:14 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JONES REST HOMEFACILITY NUMBER:
011441040
ADMINISTRATOR/
DIRECTOR:		CHARLES W DRAKEFACILITY TYPE:
740
ADDRESS:524 CALLAN AVENUETELEPHONE:
(510) 483-6200
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 31TOTAL ENROLLED CHILDREN: 0CENSUS: 14DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Della De Leon, Administrator TIME VISIT/
INSPECTION COMPLETED:
03:30 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 11/14/24 at 12:55 p.m., Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Della De Leon and explained the purpose of the visit.

LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 4 buildings and 19 total bedrooms. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 118 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Fire extinguisher was last serviced on 5/22/24. First aid supplies were observed to be adequate. LPA reviewed 6 residents records and 3 staff records.

The following deficiencies were observed:
S1 and S2 are not associated to the facility
S3 does not have a criminal records clearance

The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.
*CIVIL PENALTY ASSESSMENT $500 FOR FAILURE TO OBTAIN FINGERPRINT CLEARANCE (See Civil Penalty Assessment - Immediate).
Harpreet HumpalTELEPHONE: (510) 285-3928
Jill Clancy-CzulegerTELEPHONE: 510-286-4201
DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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
Document Has Been Signed on 11/14/2024 03:14 PM - It Cannot Be Edited

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: 11/14/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Criminal Record Clearance
(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not having a background check done for S3 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
1
2
3
4
Facility staff was removed from the facility. Facility agrees to obtain fingerprint clearence for S3 prior to returing to working at the facility. The facility also agrees to review the regulation and submit a letter of self certification to CCLD by POC date. A Civil penalty was assessed on this day for $500
Section Cited
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not by not getting S1 and S2 records cleaence transfered to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
1
2
3
4
The Staff was removed from the facility. Facility agrees to request a transfer, or obtain new fingerprint clearence proir to any new staff member working at the facility. The facility also agrees to review the regulation and submit a self certification letter to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Harpreet HumpalTELEPHONE: (510) 285-3928
Jill Clancy-CzulegerTELEPHONE: 510-286-4201

DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024

LIC809 (FAS) - (06/04)
Page: 2 of 2