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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006026
Report Date: 08/11/2021
Date Signed: 08/23/2021 09:31:24 AM

Document Has Been Signed on 08/23/2021 09:31 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:GERALD JONES ADULT RESIDENTIAL CARE FACILITY LLCFACILITY NUMBER:
306006026
ADMINISTRATOR:JONES, GERALDFACILITY TYPE:
735
ADDRESS:7 HOLLYLEAFTELEPHONE:
(818) 384-9331
CITY:ALISO VIEJOSTATE: CAZIP CODE:
92656
CAPACITY: 4CENSUS: 0DATE:
08/11/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gerald Jones & Kevin ClarkTIME COMPLETED:
01:17 PM
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Component II completion: Successful
Facility Type: ARF Application Type: INITL Capacity: 4
COMP II Participants: Gerald Jones, Administrator and Corporate board member, and Kevin Clark, Corporate board member. Interview Method: Telephone interview
On 8/11/2021, applicants and administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. A copy of PIN 20-48-ASC has been provided to the applicant as well.
During COMP II, CAB analyst confirmed Applicants' and Administrator's understanding of following areas:
1. Facility operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing readiness
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Bailey Humes
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2021
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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