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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075600534
Report Date: 09/14/2022
Date Signed: 09/14/2022 12:06:09 PM


Document Has Been Signed on 09/14/2022 12:06 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:JONED'S REST HOMEFACILITY NUMBER:
075600534
ADMINISTRATOR:BASBAS, JULIETA C.FACILITY TYPE:
740
ADDRESS:2724 VENADO CAMINOTELEPHONE:
(925) 945-6632
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Julieta BasbasTIME COMPLETED:
12:30 PM
NARRATIVE
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On 9/14/22 at 9:30 AM, Licensing Program Analyst (LPA) J. Sampair conducted an infection control annual inspection. Upon arrival, LPA explained the purpose of the visit and Licensee Julieta Basbas arrived shortly thereafter to tour the facility inside and outside with LPA.

Facility has an infection control plan in place that they are following. The designated infection control leader is the administrator. They have one central entry point that has been designated for universal entry screening with the station located near the front entrance with visitor's log, hand sanitizer, face masks, and no touch thermometer.

Facility follows daily cleaning, sanitation of frequently touched common surfaces with disinfectants. COVID-19 signs were posted to promote hand washing, cough/sneeze etiquette and physical distancing. The temperature inside of the facility was 71.2, which was in the safe temperature range. An administrator is on site more than the required 20 hour minimum each week to oversee business operations. An administrator is on site more than the required 20 hour minimum each week to oversee business operations.

Facility cited for 1 Type A and 1 Type B deficiency (refer to LIC 809-D). The hot water was dangerously high at 140 degrees Fahrenheit and they were cited for this. Facility also cited for fire extinguisher, though it was fully charged, it had been more than a year since it had been replaced.

Exit interview conducted, copy of Appeal Rights, and a copy of this report provided via email
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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 3


Document Has Been Signed on 09/14/2022 12:06 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: JONED'S REST HOME
FACILITY NUMBER: 075600534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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, because the hot water temperature was measured at 140 degrees, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2022
Plan of Correction
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Licensee reduced temperature to safe range during visit.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/14/2022 12:06 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: JONED'S REST HOME
FACILITY NUMBER: 075600534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

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 for the fire extinguisher that had been purchased more than a year before, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2022
Plan of Correction
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Licensee will have fire extinguisher serviced or purchase new fire extinguisher and send proof to LPA on or before due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3