306006026-10-5-2023-22-AS-DLMN-CWBP6B-20231005110205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006026
Report Date: 10/05/2023
Date Signed: 10/05/2023 11:02:57 AM

Document Has Been Signed on 10/05/2023 11:02 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	GERALD JONES ADULT RESIDENTIAL CARE FACILITY LLC		FACILITY NUMBER:	306006026
ADMINISTRATOR:	JONES, GERALD		FACILITY TYPE:	735
ADDRESS:	7 HOLLYLEAF		TELEPHONE:	(818) 384-9331
CITY:	ALISO VIEJO	STATE: CA	ZIP CODE:	92656
CAPACITY: 4		CENSUS: 4	DATE:	10/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Administrator - Rhodora Cruz		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at Gerald Jones Adult Residential Care Facility to conduct an unannounced Required 1 Year Inspection. At 8:45am, LPA was greeted and granted entry by AD Rhodora Cruz. Structure: The facility is a two-story home with four private resident bedrooms, three bathrooms, living room, office, kitchen, dining room, laundry room, backyard and an attached two car garage. There is one exit gate on the side of the house. There is one shaded seating area in the backyard. LPA did not observe any obstacles or hazards in the backyard. LPA observed an unused mattress and refrigerator in the garage. AD stated that the items were placed in the garage within the last week and the facility has a plan to dispose of them. Client Bedrooms: All resident bedrooms had the required furnishings. LPAs observed all resident beds had linens and blankets. LPA observed all windows were screened. Toxins: All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to client and will be stored and locked in a cabinet in the kitchen. Medications, First-Aid Kit & Files: Medication will be stored in a locked cabinet in the hallway. First aid kit is stored in the garage. Records will be kept locked in with the medication. LPA reviewed two out of four client files and two staff files. LPA interviewed one client. The other three clients were away at day program. Upon review of the Fire Drill file, LPA observed that the last drill the facility did took place in November 2022. A deficiency is being given on this day. LPA observed that the emergency disaster plan was not housed in the facility. Rafael Carbajal, Backup Administrator arrived at the facility to provide LPA with copy of Emergency Disaster Plan. LPA advised staff to print and keep a copy of the Emergency Disaster plan at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GERALD JONES ADULT RESIDENTIAL CARE FACILITY LLC	FACILITY NUMBER: 306006026
	VISIT DATE: 10/05/2023

NARRATIVE

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Fire Extinguisher: The fire extinguishers is fully charged as indicated by the arrow pointing in the green zone. LPA observed service tag to indicate the extinguisher was last serviced on 8/31/23

Activity Materials: The facility has books, magazines, and board games for client use. Clients also have their own personal items in their rooms for activities.

Bathrooms: All bathrooms have working plumbing and designated hand washing posters. Hot water measured at 109.5 degrees Fahrenheit in bathroom 1, 110.4 degrees Fahrenheit in bathroom 2 and 109.5 degrees Fahrenheit in bathroom 3.

Linens & Hygiene Supplies: A supply of extra linen was stored in the hallway cabinets upstairs.

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review

Food Service: There is a 2-day supply perishable food and 7-day supply of non-perishable food on hand.

Smoke Detectors: Smoke detectors and carbon monoxide detectors tested operational.

Appliances: Gas 5 burner stove with oven, 1 refrigerator, dish washer, microwave, washer, and dryer are operational.

Based on the observations made during today's visit, one deficiency is being cited as per Title 22 Division 6 Chapter 2 of the California Code of Regulations. An exit interview was conducted with Administrator Rhodora Cruz and Backup Administrator Rafael Carbajal, and a copy of this report an appeal rights was provided.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/05/2023 11:02 AM - It Cannot Be Edited

Created By: Dwayne L Mason On 10/05/2023 at 10:49 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GERALD JONES ADULT RESIDENTIAL CARE FACILITY LLC	FACILITY NUMBER: 306006026
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as the facility last documented emergency drill was conducted in November 2022. This poses a potential safety risk to persons in care.
	POC Due Date: 10/12/2023
	Plan of Correction
1 2 3 4	Administrator and Backup Administrator stated the facility will conduct an emergency disaster drill and email LPA the completed disaster drill form by the assigned POC due date of 10/12/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Armando J Lucero

LICENSING EVALUATOR NAME:

Dwayne L Mason

LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC809 (FAS) - (06/04)

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