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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191820013
Report Date: 09/16/2022
Date Signed: 10/25/2022 09:56:46 AM


Document Has Been Signed on 10/25/2022 09:56 AM - 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: 8DATE:
09/16/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Juanita Mitchell, Care GiverTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced case management visit to the above facility. LPA was met with Juanita Mitchell, Care giver and later spoke to Ira Jones, Licensee via telephone and the purpose of the visit was explained.

LPA and Juanita toured the entire facility inside and out. LPA observed garage is still part of the facility. It has not been demolished. The garage roof is broken and has wood exposed. The garage door is broken and crashed. Licensee built a carport right along side the garage. The carport has not been inspected by the City of Los Angeles, licensee is still waiting for the city to come out and inspect the carport. LPA observed cockroaches in the kitchen walls and cabinets. The cabinets had cockroach droppings and dead cockroaches. Licensee has not submitted new facility sketch with bedroom converted to office and ambulatory/ non-ambulatory approved. Bedroom #8 ceiling is cracked and has water damage which needs repair. It is currently being occupied by a client. The outside has 3 bent and dirty folding tables and an awning that is ripped and not providing any shade.There are broken chairs, old table, plywood, wheelchair, and paint cans that need to be removed from the back yard next to the garage.

LPA issued Technical Advisories:

1. Mitigation Plan needs to be posted and/or in a binder.
2. CDSS PIN's are not posted in the facility for staff and client review.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted with Juanita Mitchell, Care giver, and a hard copy of report was provided along with the Appeal Rights.


SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
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 03/14/2023 10:43 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/25/2022 09:57 AM

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: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited

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To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on outside awning is torn and broken, 3 folding tables are dirty and sucken in. Which poses a health and safety risk for all person in care.
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Licensee to repair or puchase new folding tables and new awning. Send pictures on or before POC due date.
Type B
09/23/2022
Section Cited

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All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.
This was not met as evidence by: Based on cockroaches in the kitchen and cabinets.
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Licensee to contract Pest Control to treat all facility and proive copy of invoice from Pest Control on or before POC due date.
Type B
09/23/2022
Section Cited

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All outdoor and indoor passageways and stairways shall be kept free of obstruction.This was not met as evidence by: Based on broken chairs, paint cans, table, wheelchair, and plywood next to garage needs to be removed. Which poses a health and risk for clients.
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Licensee to remove all items and provide piture to LPA on or before POC due date.
Type B
09/23/2022
Section Cited

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The facility shall be clean, safe, sanitary and in good repair at all times. .....
This was not met as evidence by: Based on Room#8 is occupied and ceiling is cracked and has water damage.Which poses a health and safety risk for all persons in care.
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Licensee to repair or replace ceiling for Room #8 and provide copy of repair or replacement of ceiling. Provide pictures of new or repaired ceiling on or before the POC due date.
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: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/14/2023 10:44 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/25/2022 10:20 AM

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: 09/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2022
Section Cited

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The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists..This was not met as evidence by.Based on garage not being demolitioned or repaired. Which poses a health and safety risk for all persons in care
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Licensee to demolish the garage and/or rebuilt garage. Get city of los angeles approval to rebuilt garage. Provide pictures of demolition of garage on or before POC due date.
Type B
09/23/2022
Section Cited

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Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval..This was not met as evidence by: based on licensee has not provide copy of new facility sketch
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Licensee to provide copy of new facility sketch by or on POC due date.
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with new assignment of bedroom turned into office and ambulatory or non-ambulatory aproved.
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3