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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191820013
Report Date: 05/03/2023
Date Signed: 05/03/2023 02:55:04 PM


Document Has Been Signed on 05/03/2023 02:55 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
EL SEGUNDO, 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:
05/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Mr. Ira JonesTIME COMPLETED:
01:20 PM
NARRATIVE
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On 05/03/23, Licensing program analyst (LPA) Lizeth Villegas conducted a case management visit to conduct a health and safety check. LPA met with Mr. Jones and the purpose of todays visit was explained.
During today visit LPA toured and inspected the physical plant which includes: the food supply and tour of common areas and resident rooms. LPA observed three (3) residents sleeping in the bedrooms and three (3) residents lounging in the outdoor patio area.
LPA requested and obtained copies of the following documents:
  • Emergency identification sheet for residents #1-6
  • Physician reports for residents #1-6
  • Needs and service plan for residents #1-6
  • Copy of liability insurance

Licensee to email a copy of the documents listed above by Friday May 5,2023

During today's visit LPA did not observe any immediate health and safety concerns. No deficiencies were noted.
Exit interview conducted with Mr. Jones and a copy of this report was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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 05/03/2023 02:55 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: JONES RESIDENTIAL FACILITY
FACILITY NUMBER: 191820013

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2023
Section Cited

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1569.605 Liability insurance; coverage requirements
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering
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Licensee to re-instate insurance and provide proof to licensing by POC due date.
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injury to residents and guests in the amountof at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
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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: Lizeth VillegasTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
LIC809 (FAS) - (06/04)
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