<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191820013
Report Date: 10/19/2022
Date Signed: 10/19/2022 12:29:52 PM


Document Has Been Signed on 10/19/2022 12:29 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:JONES RESIDENTIAL FACILITYFACILITY NUMBER:
191820013
ADMINISTRATOR:JONES, QUEENFACILITY TYPE:
740
ADDRESS:9307 BUDLONG AVE.TELEPHONE:
(323) 754-1516
CITY:LOS ANGELESSTATE: CAZIP CODE:
90044
CAPACITY:15CENSUS: 6DATE:
10/19/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Linda Norris, Care giverTIME COMPLETED:
12:30 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
Licensing Program Analyst (LPA) Ana Soto and LPM Janae Hammond conducted an unannounced case management- Health and safety check. LPA Soto conducted today's visit with Linda Norris, Care giver.

LPA, LPM, and Care giver toured specific areas of the facility. LPA, LPM, and Care giver toured the outside. Awning was replaced with a new umbrella. One of the three tables that was outside was removed and the other 2 tables are still dirty and were not cleaned. The garage is not repaired, it has no roof and broken garage door, and only has 4 walls. The carport has not been inspected by the City of Los Angeles. The kitchen still has live cockroaches on the walls and kitchen cabinets. Care giver informed LPA that a company comes to spot treat the facility. LPA saw facility has (roach tables for topical use,) LPA only saw box, but did not see any being used in the kitchen or cabinets. Facility did remove all the debris next to the garage between the garage and back fence. The facility repaired only part of the ceiling for Room #8. The entire ceiling had to be repaired. The facility sketch with the bedroom converted to a office has still not been updated and still not submitted. Licensee Ira Jones requested an extension for corrections. The extension granted until 10/31/22. ?? informed LPA and LPM that the facility suffered a death and was attending the clients funeral. LPA did internal investigation and no SIR was sent to CCLD. LPA cited facility for failing to report death.

An exit conducted with Linda Norris, Care giver and copy of report and appeal rights provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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 2


Document Has Been Signed on 10/19/2022 12:29 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: JONES RESIDENTIAL FACILITY
FACILITY NUMBER: 191820013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2022
Section Cited

1
2
3
4
5
6
7
87211.a1A Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This was not met as evidence by: Based on facilityFailed to report death of resident.Which posed
8
9
10
11
12
13
14
Based on facility Failed to report death of resident.Which posed a potential health and safety risk for all persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2