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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191820013
Report Date: 11/18/2022
Date Signed: 11/18/2022 03:53:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2022 and conducted by Evaluator Ana Soto
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221021135251
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:
11/18/2022
UNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Juanita Mitchell, Care GiverTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not keep the facility free from bed bug infestation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ana Soto conducted a subsequent complaint investigation to deliver findings and decisions for the allegation listed above. Today’s complaint investigation was conducted with Juanita Mitchell, Care giver

The investigation consisted of following: Interviews and Record reviews. On 10/24/22, LPA Soto interviewed LPA Soto interviewed S#1 & S#2, R#1 – R#4. LPA Soto received the following documents on 10/24/2022: Resident and Staff roster and invoice of treatments for bed bugs. LPA also took pictures of the beds and bed sheet of rooms 9, 11, 12, and 13.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20221021135251
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 11/18/2022
NARRATIVE
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Based on the LPA's investigation, the investigation revealed the following;
Allegation – Staff did not keep the facility free from bed bug infestation. Interviews conducted with residents, communicated that they had beg bugs, but the hadn’t seen any for several days. Interview with S#1 communicated that they had a few months ago, but he got a pest company to come and treat the facility and they seemed to have gotten rid of the bed bugs. Administrator provided the invoices for the pest control. Interview with S#2, communicated that the facility still has bed bugs. The administrator treats the facility but doesn’t get rid of the problem. LPA toured the facility and observed bed bugs in 4 rooms. Rooms #9, 11, 12, 13. The sheet were still stained with the bed bug feces. LPA reviewed the invoices; the pest control has just conducted spot treatments. The interviews, observation, and records reviewed do concur with the above allegation.

Based on LPA’s observations and interviews which were conducted and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

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: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20221021135251
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2022
Section Cited
CCR
87303(a)
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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: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC9099 (FAS) - (06/04)
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