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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191820013
Report Date: 03/10/2023
Date Signed: 03/13/2023 09:08:14 AM


Document Has Been Signed on 03/13/2023 09:08 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: 6DATE:
03/10/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Juanita Mitchell, Care giverTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced POC visit to the above facility, to ensure the deficiencies cited on multiple dates were cleared. LPA met with Juanita Mitchell, Care giver and the purpose of visit was explained.

On 11/08/22, LPA cited 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times.... POC due date was 12/05/22. Licensee failed to provide proof of correction. LPA cited deficiency.

On 09/16/22, LPA cited 87555(b)(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.POC due date was 09/23/22. Licensee failed to provide proof of correction. LPA cited deficiency.

On 09/16/22, LPA cited 87305(b) 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.... Licensee failed to provide proof of correction. LPA cited deficiency.

If proof correction of deficiencies are not received by POC due date, civil penalties will be accessed.

RO will be holding an NCC at a future date.

An exit interview was conducted with Juanita Mitchell, Care Giver, and a hard copy of report and Appeal rights was provided
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
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 03/13/2023 09:08 AM - 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: 03/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2023
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
03/15/2023
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
03/15/2023
Section Cited

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This was not met as evidenced by:
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Administrator to have pest control treat the entire facility and send proof of treatment to LPA by POC due date.
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based on bed bug feces on beds. Which poses a potential risk for all those in care.
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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: 03/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2