191820013-6-29-2021-11-AS-JCAS-C4FUMW-20210629154302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191820013
Report Date: 06/29/2021
Date Signed: 06/29/2021 03:48:00 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME:	JONES RESIDENTIAL FACILITY		FACILITY NUMBER:	191820013
ADMINISTRATOR:	JONES, QUEEN		FACILITY TYPE:	740
ADDRESS:	9307 BUDLONG AVE.		TELEPHONE:	(323) 754-1516
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90044
CAPACITY:	15	CENSUS: 6	DATE:	06/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Ira Jones		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Jey Cardenas conducted an unannounced required annual visit with a primary focus on Infection Control measures using the new CARE Inspection Tools. Upon arrival at the facility, LPA Cardenas called Administrator Ira Jones and conducted a risk assessment over the telephone. Based on the assessment, the facility is clear of Covid-19 infection. LPA verified that the facility has an approved mitigation plan report.

The facility is licensed for fifteen 15 residents (11) non-ambulatory residents and four (4) ambulatory. Currently there are 6 residents in care.

LPA met with administrator; Mr. Jones LPA was screened for Covid-19 symptoms and temperature was checked. Both toured the inside and outside grounds of the facility.

The home consists of a total of ten (10) bedrooms; of which eight (8) are designated as resident bedrooms, one (1) staff bedroom, and one (1) used as an office space. Three (3) bathrooms, living room, dining room, and kitchen, shaded patio area. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. All residents have a private bedroom. Resident bathrooms were checked, toilets and water faucets worked properly, sufficient liquid soap and paper towels were observed. LPA toured the kitchen area and observed sufficient perishable and non-perishable food.

During the tour, LPA observed the facility’s infection control practices: LPA didn’t observe a sanitizing station at the facility entrance; no visitors log with Covid-19 screening and temperature log observed, no records of daily Covid-19 screening and temperature checks of residents and staff were observed. PPE supplies are readily available to staff, and an additional 30-day supply of PPE. Sufficient paper, cleaning, and disinfecting supplies were observed. The facility’s designated visitation area is the front patio area. LPA observed residents weren’t maintaining 6 feet physical distancing. LPA observed required postings throughout the facility.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

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, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: JONES RESIDENTIAL FACILITY	FACILITY NUMBER: 191820013
	VISIT DATE: 06/29/2021

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Outside grounds were toured, and no bodies of water were observed. Walkways around the home were clear of hazards. Common areas were clean and clear of hazards; doorways were free of obstructions.

Advisory Notes with technical assistance were issued.

1. LPA did not observe posted copies of CDSS PINs available to staff/ residents.
2. License failed to complete the N-95 Fit Testing requirement for all staff. q
3. Residents were not maintaining social distancing.
4. LPA didn’t observe cleaning logs/ plan for disinfecting sanitizing surfaces.
5. No sanitation station at main entry.
6. Daily screenings records for staff/ residents were not being completed.
7. Submit updated facility sketch labeling (office)/ bed number, and if ambulatory/ non-ambulatory approved.
8. Bedroom #8 needs roof repair (bedroom is vacant and currently inaccessible to residents)
9. Follow up with zoning re: garage removal.

No deficiencies were cited during this visit. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Angela J Kendrick	TELEPHONE: (323) 629-7815
LICENSING EVALUATOR NAME: Jey Cardenas	TELEPHONE: (323) 383-8188
LICENSING EVALUATOR SIGNATURE:	DATE: 06/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021

LIC809 (FAS) - (06/04)

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