197610334-2-27-2023-31-AS-SSTS-CPG2AG-20230227161331

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610334
Report Date: 02/27/2023
Date Signed: 02/27/2023 04:14:21 PM

Document Has Been Signed on 02/27/2023 04:14 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	JONES LOVE CARE ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	197610334
ADMINISTRATOR:	COUNTS, KENE		FACILITY TYPE:	735
ADDRESS:	1711 EAST MESA DRIVE		TELEPHONE:	(714) 200-6139
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 4		CENSUS: 0	DATE:	02/27/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Kristy Jones, Licensee		TIME COMPLETED:	04:20 PM

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Licensing Program Analyst (LPA) Shira Stamps met with Kristy Jones (Licensee/Applicant) and Kene Counts (Administrator) for a Pre-licensing inspection at 12:50 pm.

Entrance interview conducted.

The home will be vendored by North Los Angeles Regional Center. The home will serve four (4) level 4 intellectually disabled adults. Clients will be all ambulatory. The facility has five (5) bedrooms and two (2) and a half bathrooms designated for a capacity of four (4) clients. One(1) bedroom is designated for staff only, and the office will be locked at all times. Staff will be awake at night.

The physical plant was toured inside and out at 1:10 pm.

Common Area: LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The facility maintains a comfortable temperature at 70 degrees F, which meet regulations. The air conditioner is operational. No firearms observed or will be maintained on the premises. The smoke alarm and dual carbon monoxide detectors were operational and tested at 1:22 pm. Fire extinguishers appear to be full, but receipt or serviced date was not available. The Licensee stated she will provide the receipt and place it on all fire extinguishers..

Resident rooms: Rooms available are all private. LPA observed rooms to have bedding sheets, pillowcase, blankets which are in good condition. The mattress pads were not placed on the beds yet, and the plastic needs to be removed from all mattresses. There is at least one chair, a night stand, and sufficient lighting for each client. The mattresses and bedsprings were also checked for condition. Window covering and window screens are in good repair. Room #4 needs a screen. Room #5 designated for the office has a balcony, but the office is to be locked at all times. CONTINUED...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JONES LOVE CARE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 197610334
	VISIT DATE: 02/27/2023

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Window covering and window screens are in good repair. Room #4 needs a screen. Room #5 designated for the office has a balcony, but the office is to be locked at all times.

Consumers will have sufficient amounts of supplies for personal hygiene products, which is provided by the Licensee.

Bathrooms: LPA toured client bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured at 149.9. The Licensee has appropriate non-skid mat in each shower. Trash cans needed in each restroom with lids to protect consumers from cross contamination. Towels and washcloths will not be shared.

Kitchen Area: LPA inspected kitchen equipment. The refrigerator was clean and in good operation. Dishes in good repair. Knives and cleaning supplies will be kept locked inaccessible in the kitchen cabinet under the sink.

Medications will be kept centrally stored and locked a closet located in the downstairs hallway. Stove and refrigerator are clean and in good operation. LPA observed sufficient supply of 7 day non-perishable foods.

Outside: LPA toured the outside area. LPA observed a covered shaded area for clients. No bodies of water observed on the premises. LPA observed a portable fire pit with a covering. The Licensee stated she was going to remove the pit. LPA informed her of regulation laws regarding firepits.

Garage: The garage is attached to the facility. It will be locked and inaccessible to clients.

Files will be kept confidentially stored in the office.

LPA discussed preplacement, staffing, training, customer service, inspection authority, reporting requirements (mandated reporter), records, citations, criminal record clearance, civil penalties, labor law, activities, expectation is to follow all rules and regulations.

Applicant/ Administrator has completed component III.

CONTINUED...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JONES LOVE CARE ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 197610334
	VISIT DATE: 02/27/2023

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The licensee will need to complete the following before the license is approved.

1. Three (3) Trash cans with lids in all bathrooms to protect from cross contamination. Submit receipt for the trash can.

2. Clean blinds in all bedrooms. Submit a photo for each room.

3. Label all rooms with numbers. Will be reviewed at second visit.

4. Remove the fish tank. Will be reviewed at second visit.

5. Put a lock on the laundry room door. Will be reviewed at second visit.

6. Create five(5) Covid symptom screening questions and log in for visitors. Submit questions via email.

7. Clean all cabinets in three (3) bathrooms, laundry room, and kitchen. Will be reviewed at second visit.

8. Place receipt on fire extinguishers. Submit a photo.

9. Notify LPA when land line is turned on. LPA will call the facility number to verify it is working.

10. Redo facility sketch for first and second floor.

11. Remove plastic from all mattresses and place mattress pads on all beds. Will be reviewed at second visit.

12. Post all COVID signs throughout the facility. Will be reviewed at second visit. (Including wash your hand signs)

13. Post a bigger size poster for the complaint sign.

14. Bathroom #2 upstairs clean rust in the mirror or replace it. Submit a photo.

15. Place night-lights in the hallways. Will be reviewed at second visit.

16. Place paper towel in all bathrooms. Submit a photo.

17. Take satellite hanging down on side of the house. Submit a photo.

18. Remove broken screen door frame on the front door. Submit a photo.

The facility is ready for operation upon correction of requested items in this report, and final approval of the application. Submit items for correction no later March 03/15/2023.

Exit interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC809 (FAS) - (06/04)

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