<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006026
Report Date: 10/10/2022
Date Signed: 10/10/2022 12:54:38 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/10/2022 12:54 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: 2DATE:
10/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Rhoda Cruz, Direct Service Professional, Gerald Jones (Licensse, Administrator-Via telephone) and Rafael Carbajal, Back Up Administrator (Via Telephone)TIME COMPLETED:
12:59 PM
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
On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz arrived to facility on or about 9:25am with no response to door bell or via telephone to phone number provided to Community Care Licensing Department.

LPA Quiroz called and spoke to Licensee/Administrator (L/AD) Gerald Jones at phone number provided on LIC 808 mitigation plan page 11 who indicated he would not be able to attend today's Annual Facility Inspection Visit and that another Administrator from Sister Facility would assist LPA Quiroz with today's Annual inspection. On or about 10:50am, LPA Quiroz received an incoming call from Administrator (AD)Rafael Carbajal indicating he would not be able to attend today's annual inspection visit due to personal situation. LPA Quiroz was granted entry into facility at 11:07am by Direct Service Professional 1 (DSP 1). LPA Quiroz met with (DSP1) and discussed purpose of today's visit. LPA Rosie Quiroz called and spoke to (L/AD) Gerald Jones and (AD) Rafael Carbajal and explained the nature of the visit. Facility indicated screening all incoming visitors prior to entering the facility. Facility is licensed to provide services to Developmentally disabled clients, age range 18 through 59 years of age, 4 Ambulatory clients only. This is a Level 4 I facility. Facility is currently providing services to two clients. Administrator Gerald Jones has a current Administrator certificate with expiration date of June 23, 2024.

On or about 11:22am, LPA Rosie Quiroz along with (DSP1) began the tour of the inside and outside of the facility. There are two (2) clients in care and there are no active COVID-19 cases in the facility. LPA Quiroz observed two of two clients in their bedrooms. LPA Quiroz interacted and interviewed with client's during today's visit. Two of two clients appeared to be clean and well taken care of. LPA Quiroz observed a COVID-19 check in station in the entry of the facility. LPA Quiroz observed required department COVID-19 precautionary postings in the facility as well as hand washing signs throughout the facility. Facility temperature recorded to be 70 degrees fahrenheit.

CONTINUED...

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 10/10/2022 12:54 PM - It Cannot Be Edited


Created By: Rosie Quiroz On 10/10/2022 at 12:03 PM
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: 10/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2022
Section Cited
CCR
85068.1(a)(d)

1
2
3
4
5
6
7
85068.1(a)(d)Admission Procedures: (a)The licensee shall develop, maintain, and implement admission procedures which shall meet the requirements...(d)The facility shall obtain the medical assessment, performed as specified in Section 80069.This requirement was not met as evidenced by: CONTINUED
1
2
3
4
5
6
7
Licensee/Administrator Gerald Jones will submit physician reports for C1 and C2 to CCL by POC Due date of 10/14/2022.
8
9
10
11
12
13
14
During today's inspection visit, LIC 602 (Physician Report) missing for C1 and C2, this was verified with L/AD Gerald Jones and AD Rafael Carbajal. L/AD Jones indicated "Issues with Doctor completeing C2's physicain report and C1 is probably at sister facility, I'd have to locate it."
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 10/10/2022
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
26
27
28
29
30
31
32
CONTINUED...

All restrooms observed to have a supply of soap, appeared to be clean and water temperatures were recorded to be within normal limits. LPA Quiroz inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food, water and PPE in garage area and kitchen area readily available for staff and residents. LPA Quiroz toured the outside of the facility and observed seating and shaded area for client's and visitor's enjoyment in backyard area. The facility has completed the LIC 808 Mitigation Plan. The LIC 808 plan was received and approved by the Department on September 15, 2021.

LPA Quiroz was informed that all clients and staff have had their COVID-19 vaccinations and first Booster and Facility indicated to be recording client's temperatures daily.

During today's visit, LPA Quiroz provided Consultation on Title 22 and COVID-19 Infection control throughout today's visit.

Based on the observation made during today’s visit, deficiency noted today per Title 22 Division 6 of the California Code of Regulations. Technical Violation 9102 noted during today's visit. (See LIC 809-D, and LIC 9102 TV). (L/AD) Jones will submit LIC 500 (Personnel Report) by COB 10/10/2022.

This report was reviewed with (L/AD) Gerald Jones via telephone and with (DSP1) on site. Today's report was signed by (DSP1). A copy of this report, LIC 809-D, LIC 9102 TV, Appeal Rights and LIC 811s Confidential Names were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3