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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610334
Report Date: 04/03/2023
Date Signed: 04/03/2023 01:19:44 PM

Document Has Been Signed on 04/03/2023 01:19 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 FACILITYFACILITY NUMBER:
197610334
ADMINISTRATOR:COUNTS, KENEFACILITY TYPE:
735
ADDRESS:1711 EAST MESA DRIVETELEPHONE:
(714) 200-6139
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 0DATE:
04/03/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Kristy Jones, Licensee/ApplicantTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Shira Stamps met with Kristy Jones (Licensee/Applicant) at approximately 12:20 pm for a case management visit.

Entrance interview conducted.

The purpose of the case management is to verify the items needed to be completed in the pre-licensing visit. LPA conducted a physical plant tour from 11:35-12:30pm. The items needed to be completed are listed below:

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

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

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

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

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

6. Create five (5) Covid symptom screening questions and log in for visitors. Submit questions via email. -COMPLETED 3/1/23 COMPLETED TODAY

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

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

CONTINUED...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2023
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: 04/03/2023
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13. Post a bigger size poster for the complaint sign. NOT COMPLETED TODAY

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

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

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

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

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



19. Hot water measured over 120. Retest Water. COMPLETED TODAY 119.9

Licensee needs a bigger complaint poster and a smoke detector in room #3. Licensee will submit a photo by 4/07/23. Exit interview completed. Report delivered to Licensee/Applicant.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
LIC809 (FAS) - (06/04)
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