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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003287
Report Date: 10/20/2021
Date Signed: 10/20/2021 01:13:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:JONES CAREFACILITY NUMBER:
347003287
ADMINISTRATOR:JONES, JIMMIEFACILITY TYPE:
740
ADDRESS:9559 LAZY SADDLE WAYTELEPHONE:
(916) 761-5204
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Rebeca FullerTIME COMPLETED:
01:20 PM
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On 10/20/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted an unannounced 1-year required infection control inspection. At approximately 12:20 PM, LPA met with staff member, Rebeca Fuller, at the entrance of the facility and explained the purpose of the visit. LPA was sanitized following the facility's entrance health and safety procedures. LPA also had his temperature checked and logged and then signed into the facility.

At approximately 12:30 PM, LPA toured the physical plant with the staff member. The physical plant is consistent with the submitted facility floor plan and has the COVID-19 health and safety signage. There are no obstructions blocking indoor and outdoor passageways. No pools or bodies of water observed. The facility's kitchen is free of debris. Facility refrigerator is stocked with meats, eggs, vegetables, milk, and fruit. Seven-day non-perishable food supply and two-day perishable food supply is sufficient. At 12:35 PM, LPA observed the facility's restrooms as clean and equipped with hand washing signage. The facility's backyard was free of debris.

The clients' bedrooms were inspected and all had the required lighting and furniture. Facility was equipped with smoke detectors and carbon monoxide detectors. LPA also observed the fire extinguisher as current. The facility's first aid kit included the required tweezers, scissors, and a thermometer. Cleaning solutions are stored and locked. Medication supply is also stored and locked. PPE supply is sufficient. Additional wipes and sanitizer are stored in the garage.

At approximately 12:45 PM, LPA completed the tour of the facility and began writing this report. LPA reviewed facility procedures for visitation entrance, temperature checks and logs, COVID-19 isolation, PPE, food and cleaning supply storage.

No deficiencies were cited today. Exit interview conducted with the staff member. A copy of this report will be emailed to the facility.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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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