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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071441088
Report Date: 12/15/2023
Date Signed: 12/15/2023 05:11:39 PM

Document Has Been Signed on 12/15/2023 05:11 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JONES FAMILY HOMEFACILITY NUMBER:
071441088
ADMINISTRATOR:DAVID & SHIRLEY JONESFACILITY TYPE:
735
ADDRESS:180 FRANCISCAN DRIVETELEPHONE:
(925) 838-4216
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 6CENSUS: 3DATE:
12/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:16 PM
MET WITH:Licensee, David JonesTIME COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) A. Gomez arrived unannounced on this date to conduct 1-Year Annual Inspection starting at 3:00pm. Upon arrival, LPA met with Licensee, David Jones. Administrator, Shirley Jones arrived at 3:15pm. The facility's fire clearance was approved for ambulatory only.

LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water. A comfortable temperature for clients is maintained at 74 degree Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the shared clients’ bathroom was measured at 108.5 degree Fahrenheit. All toilets, hand washing and bathing are safe, sanitary and in operating condition. The supply of extra hygiene were available for residents. There are a minimum of 7-day nonperishables and 2-day perishables foods.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 8/14/2023 . First aid kit was observed to be complete. Disaster drill was last conducted on 10/14/2023.
    LPA reviewed 2 staff records and staff are associated to the facility and have current first aid training. LPA reviewed 3 clients records and P&I's.



Report continues on 809C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: JONES FAMILY HOME
FACILITY NUMBER: 071441088
VISIT DATE: 12/15/2023
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The following deficiencies were observed
  • 4:10pm During record review LPA observed P&I log not up to date.
  • At 4:00pm during record review, LPA observed C3's IPP or Needs and Services Plan is not current.


The following forms to be updated and submitted to CCL by 12/31/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610D Emergency Disaster Plan
Liability Insurance
Current Administrator's Certificate

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties.

Exit interview conducted and a copy of this report provided
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/15/2023 05:11 PM - It Cannot Be Edited


Created By: Alona Gomez On 12/15/2023 at 04:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: JONES FAMILY HOME
FACILITY NUMBER: 071441088

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068.2(b)(1)
80068.2(b)(1) Needs and Services Plan
If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency..The needs appraisal or IPP is not more than one year old.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, Licensee failed to obtain a current Needs and Services plan or IPP for C3 which poses a potential health and safety risk to clients in care.
POC Due Date: 12/31/2023
Plan of Correction
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By POC date Administrator agreed to obtain a current Needs and Services Plan or IPP for C3 and fax a copy to CCLD
Type B
Section Cited
CCR
80026(h)
80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in having P&I records incomplete and unavailable for review which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2023
Plan of Correction
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By POC date Administrator agreed to complete P&I records and submit copies to CCLD.
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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023


LIC809 (FAS) - (06/04)
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