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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006026
Report Date: 10/08/2021
Date Signed: 10/08/2021 02:04:45 PM

Document Has Been Signed on 10/08/2021 02:04 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
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:
10/08/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gerald Jones and Kevin ClarkTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an announced pre-licensing visit. LPA identified herself and discussed the purpose of the visit with Licensees Kevin Clark and Gerald Jones. An initial application to operate an Adult Residential Facility was received by CCL on 06/14/2021 for a capacity of 4 ambulatory residents. Administrator Gerald Jones has a current administrator certificate expiring on 06/23/2022. There are no clients in care during today's visit. Facility has covid signage in the facility and LPA observed the screening/ sanitation station in the entrance of the facility.
LPA Lyman along with Licensees Clark and Jones toured the facility at 9:19 AM and observed the following:
Structure: Facility is a two story, 4 bedroom, 3 bathroom house with an attached garage and a light tan exterior. The exit gate is closed and unlocked. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Clients: All bedrooms are single occupancy. All rooms are equipped with appropriate lighting, chair, night stand, ample closet space. Bathrooms: All client restrooms have a working toilet/ wash basin as well as paper towels in all restrooms. There are hand washing signs in all restrooms. Linens & Hygiene Supplies: Linen supply is in ample supply for clients in care. Emergency Phone Numbers and Exit Plan: Licensee to post in the entrance area of the facility. Food Service: Facility has ample 7 day non-perishables in the pantry. Facility to obtain perishable food upon acceptance of clients. LPA observed a sample menu. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are fully charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins: Stored in a locked area in the garage. Water Temperature: Tested and recorded between 108.6 and 110.0 degrees F.in facility bathrooms. Emergency Supplies: LPA observed ample emergency food and water. Medications, First-Aid Kit & Book: First aid kit observed contained all required items. Licensee ordered a first aid manual during the visit. Medication to be stored and locked in a locked closet in the facility. Facility uses a medication administration record
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GERALD JONES ADULT RESIDENTIAL CARE FACILITY LLC
FACILITY NUMBER: 306006026
VISIT DATE: 10/08/2021
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Resident & Staff File: Records to be locked in a closet in the hallway. Reading Material, Games, and Equipment: LPA observed reading materials in the facility. Facility activity schedule includes exercise, music therapy, drawing, and games. Additional activities include outings in the community. Backyard: LPA observed a clean, safe backyard with shaded seating for clients. Fire Clearance: Approved for 4 ambulatory residents on 07/27/2021.

Licensee to address the following items:
  • Please obtain additional outdoor seating
  • Please enlarge the "Let Us No" poster and re-post in entrance of facility
  • Please post covid precaution signage at main outside entrance.


The facility is ready to be licensed. Component III not conducted during visit as Licensees currently have two operating facilities.

An exit interview was conducted with Licensees and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC809 (FAS) - (06/04)
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