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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206810
Report Date: 11/15/2021
Date Signed: 11/15/2021 06:49:33 PM

Document Has Been Signed on 11/15/2021 06:49 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:JONES HOME 2FACILITY NUMBER:
107206810
ADMINISTRATOR:JONES, SHONDAFACILITY TYPE:
735
ADDRESS:3525 N GLENNTELEPHONE:
(559) 385-7411
CITY:FRESNOSTATE: CAZIP CODE:
93704
CAPACITY: 6CENSUS: 4DATE:
11/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Shonda Jones, Licensee/AdministratorTIME COMPLETED:
05:20 PM
NARRATIVE
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On 11/15/21 at 2:45 PM, Licensing Program Analyst (LPA) Malia Thao arrived unannounced to conduct an Annual inspection. LPA was greeted by staff and granted entry. Licensee (LIC) Shonda Jones arrived a short later.

Facility was observed without any obstructions. Hand sanitizer was readily available to residents and visitors. Hand washing posters were observed by the bathroom sinks. Bedrooms were checked and no residents share a room. LPA checked residents’ medications. Medications are refilled as needed. Food supply was observed in adequate supply. Cleaning and PPE supplies were checked. Residents files have updated emergency contact information. Administrator certification is valid.

The following deficiencies observed:
1. Both fire extinguishers were last serviced 6/1/2020.
2. Bedroom #1: Window blinds is in disrepair, missing section of slats, and carpet observed with dark areas.
Bedroom #2: Window sill observed covered in dirt and sticky. Area of carpet in middle of bedroom observed with dark colored stain. Door observed punched in approximately 4" by 4". Bedroom #3: Carpet observed with dark areas. Garage: Exterior of garage door, door step plate, and garage floor is covered in dirt and stains. Back patio observed covered in dirt and stains.
3. Trash bin in kitchen and hall bathroom observed without tight-fitting lids.

Deficiencies are being cited based on LPA observations and interviews conducted in accordance with the California Code of Regulations, Title 22, see LIC9909D.

Exit interview was conducted. A copy of this report and appeal rights were emailed to email on record with "Read receipt" to confirm receipt of this report.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Malia Thao
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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 5
Document Has Been Signed on 11/15/2021 06:49 PM - It Cannot Be Edited


Created By: Malia Thao On 11/15/2021 at 04:30 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: JONES HOME 2
FACILITY NUMBER: 107206810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and record review, the licensee did not comply with the section cited above in two out of two fire extinguishers. Both fire extinguishers observed with tags of last service date of 6/1/2020, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2021
Plan of Correction
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Licensee will submit proof of fire extinguishers re-tagged with current servicing date to CCL by POC due 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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/15/2021 06:49 PM - It Cannot Be Edited


Created By: Malia Thao On 11/15/2021 at 04:30 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: JONES HOME 2
FACILITY NUMBER: 107206810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. Bedroom #1: Window blinds is in disrepair, missing section of slats, carpet observed with dark areas. Bedroom #2: Window sill observed covered in dirt and sticky. Area of carpet in middle of bedroom observed with dark colored stain. Door observed punched in approximately 4" by 4". Bedroom #3: Carpet observed with dark areas. Garage: Exterior of garage door, door step plate, and garage floor is covered in dirt and stains. Back patio observed covered in dirt and stains. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2021
Plan of Correction
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Licensee will replace Bedroom #1 blinds to curtains, clean bedroom #2 window sill, carpet clean all resident bedrooms, repair Bedroom #2 hole in door, clean garage door, door step plate, and garage floor, and clean back patio area. LPA will return for POC inspection.
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interview, the licensee did not comply with the section cited above. Trash bin in kitchen and hall bathroom observed without tight-fitting lids, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2021
Plan of Correction
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Licensee will purchase new trash bins with tight-fitting lids for kitchen and hall bathroom. LPA will return for POC inspection.
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:Andy Xiong
LICENSING EVALUATOR NAME:Malia Thao
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2021


LIC809 (FAS) - (06/04)
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