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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003287
Report Date: 01/12/2022
Date Signed: 01/12/2022 04:51:25 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:
01/12/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Jimmie Jones, LicenseeTIME COMPLETED:
11:35 AM
NARRATIVE
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On 01/12/2022 around 8:00 am, Licensing Program Analysts (LPAs) T. White and M. Jensen spoke with Licensee, Jimmie Jones regarding facility risk assessment questions. Licensee confirmed no staff or clients have experienced symptoms within the last 10 days. At 9:05 am, LPA T. White and M. Jensen arrived unannounced to conduct a required 1-year annual inspection. LPA smet with Licensee and explained the purpose of today’s inspection. LPAs was allowed entry into the facility that is licensed to serve a total capacity of 6 non-ambulatory residents.

LPAs toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105 and 112.3 degrees Fahrenheit. There is a minimum of 7-day supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide were in operating condition during inspection. Fire extinguisher was last serviced on August 09, 2021. First aid kit was observed to be complete. Fire drill was last conducted on 12/16/2021. LPA observed mitigation plan completed.

LPAs observed the following deficiencies:
- LPAs observed unlocked chemicals (Hydrogen Peroxide) accessible to residents in care located in hallway cabinet. Deficiency cleared during inspection
- LPAs observed residents shared bathroom faucet and Resident #1 (R1) dresser not in good repair.

Report continues on 809C.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: JONES CARE
FACILITY NUMBER: 347003287
VISIT DATE: 01/12/2022
NARRATIVE
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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 01/21/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties.

Exit interview conducted with Licensee. A copy of report and appeal rights given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: JONES CARE
FACILITY NUMBER: 347003287
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia:

(f) The following shall be stored inaccessible to residents with dementia:
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 87705(f)(2). LPA observed Hydrogen Peroxide and other chemicals accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/13/2022
Plan of Correction
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Licensee agreed to remove chemicals from unlocked hallway and locked it away. Deficiency cleared during the inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: JONES CARE
FACILITY NUMBER: 347003287
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintence and Operation:

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 87303(a). LPA observed dresser and residents shared bathroom faucet not in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2022
Plan of Correction
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Licensee agreed to repair faucet and Resident #1 (R1) drawer and submit proof to CCLD by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4