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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003287
Report Date: 01/13/2023
Date Signed: 01/13/2023 12:58:57 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/13/2023 12:58 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, 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: 5DATE:
01/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jimmie Jones, AdministratorTIME COMPLETED:
11:00 AM
NARRATIVE
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On 01/13/2023 at 9:00 am Licensing Program Analyst (LPA) Renee Campbell arrived at facility to conduct a annual inspection. LPA Campbell met with licensee, Jimmie Jones and explained the purpose of today's visit. The licensee will also act as the administrator and holds current administrator certificate #6003191740.

The facility will serve a maximum capacity of 6 non-ambulatory residents. The facility includes a garage, staff quarters and laundry room. The main entrance has COVID signs posted and a thermometer to screen visitors and staff. The facility has a 30 day supply of PPE available.
The main structure consists of a living room, kitchen, two bathrooms and one double occupancy bedroom and 4 single occupancy bedrooms. The facility was observed to be sanitary and free of odor. The facility was also observed to be equipped with adequate lighting and furnishings for the comfort of the residents. Night lights were present in the hallways and emergency lighting was available.

The fire extinguisher was last serviced in August of 2022 and is in compliance. The carbon monoxide and fire alarm were tested and found to be in good working order. A first aid kit was available and observed to be complete. The thermostat was set at 72 degrees and is in the required range of 68-85 degrees. The water temperature was measured in the kitchen at 106 degrees and is within the required regulatory range of 105-120 degrees. Of the two staff members, one staff was missing a health screening that needed to be replaced. The kitchen contains a locked cabinet for resident medications. There is a separate locked cabinet for cleaning supplies. Of the files reviewed, 2 of 2 personnel files and 2 of 5 resident files were reviewed.

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

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
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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Document Has Been Signed on 01/13/2023 12:58 PM - It Cannot Be Edited

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: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2023
Section Cited

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87412 Personnel Records (a)Each personnel record shall contain the following information:(11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evideced by
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Licensee will ensure employee completes a Health Screening and chest x-ray by POC due date.
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Based on file review, the licensee did not ensure a health screening was present for employee which poses a potential Health, Safety or Personal Rights risk to persons in care.
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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: Renee CampbellTELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
LIC809 (FAS) - (06/04)
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