071441088-5-20-2022-15-AS-LFRO-CELS6T-20220520133630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 071441088
Report Date: 05/20/2022
Date Signed: 05/20/2022 01:36:45 PM

Document Has Been Signed on 05/20/2022 01:36 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 FAMILY HOME		FACILITY NUMBER:	071441088
ADMINISTRATOR:	DAVID & SHIRLEY JONES		FACILITY TYPE:	735
ADDRESS:	180 FRANCISCAN DRIVE		TELEPHONE:	(925) 838-4216
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	6	CENSUS: 3	DATE:	05/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	David Jones, Staff		TIME COMPLETED:	01:50 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 5/20/2022 at 11:40 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct Infection Control Inspection. Upon arrival, LPAs were greeted by Care Staff, David Jones. Administrator, Shirley Jones later arrived at 12:00 PM. During the Infection Control Inspection, LPA toured facility with Administrator including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Common touched surfaces are disinfected at least once daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids. Facility has PPEs maintained at central location and easily accessible for staff. At 11:55 AM, LPAs reviewed 2 staff records and 2 of 2 staff have health screening and TB test results on file. Facility has a mitigation plan. THE FOLLOWING DEFICIENCY WAS OBSERVED: -At 12:40 PM during interview and record review, LPAs were informed by S1 that S1 does not have access to internet and email. Administrator is not able to obtain Provider's Information Notification (PINs) and receive any communication from CCLD via email. REPORT CONTINUES ON 809C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JONES FAMILY HOME	FACILITY NUMBER: 071441088
	VISIT DATE: 05/20/2022

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 5/27/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E 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 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/20/2022 01:36 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 FAMILY HOME	FACILITY NUMBER: 071441088
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80064(b)

80064(b) Administrator - Qualifications and Duties (b) Each licensee shall make provision for continuing operation and carrying out of the administrator's responsibilities during any absence of the administrator. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. LPAs discovered Administrator is not able to stay up to date with CCLD communication and Provider's Information Notification due to not having access to internet and email which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2022
	Plan of Correction
1 2 3 4	Administrator will review regulation and hire an assistant or new Administrator that has access to internet, emails and communication from CCLD. Admnistrator will submit a self-certification letter and a copy of new hire's record including but not limtied to: LIC 500, LIC 501, LIC 508 and LIC 503 by POC date,

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC809 (FAS) - (06/04)

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