347003582-12-22-2023-27-AS-JICY-CYRMN5-20231222084459

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347003582
Report Date: 09/20/2023
Date Signed: 12/22/2023 08:45:31 AM

Document Has Been Signed on 12/22/2023 08:45 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
SACRAMENTO SOUTH ASC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	JONES FAMILY HOME		FACILITY NUMBER:	347003582
ADMINISTRATOR:	RICHARDS, SHIRLEY		FACILITY TYPE:	735
ADDRESS:	4275 ARDWELL WAY		TELEPHONE:	(916) 424-8209
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95823
CAPACITY: 6		CENSUS: 4	DATE:	09/20/2023
TYPE OF VISIT:	Case Management - Health Checks	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Shirley Richards		TIME COMPLETED:	12:00 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	Licensing Program Analyst (LPA)s Jamie Ivey Canady and Albert Johnson arrived to the facility unannounced to conduct a case management visit. LPA met with facility administrator Shirley Richards, and explained the purpose of the visit. LPAs toured the facility to ensure the health and safety of the residents. The census is 4 residents in day program (2 Pride, 2 Short Center South) R1 is currently in Rehab at Bruceville Terrace, and according to facility administrator will not be returning to facility after having transitioned from the facility on 8/10/2023. LPAs observed Administrator Shirley to be currently incapacitated stating there are some minor health issues at this time. Caregiver Nicolette Delacruz is currently out of the facility retrieving supplies. LPAs requested and reviewed resident facility file for R1. LPAs observed R1s most recent IPP plan dated 5/19/2023. Con't 809-C

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: JONES FAMILY HOME	FACILITY NUMBER: 347003582
	VISIT DATE: 09/20/2023

NARRATIVE

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LPAs Observed bedroom for R1 which is located on the lower level of the facility. Administrator explained R1 would enter and exit from the facility on the lower level of the facility and R1s bathroom is located directly from R1s room. Facility caregiver arrived to the facility approximately 20 minutes into the LPAs visit and provided LPAs with R1 binder and notes. Nicollete stated R1 was going to the restroom at 3 am and was defecating on self and slipped on the excrement. Administrator stated she knew what happened the minute she heard the bang and R1 was provided immediate assistance. Administrator called 911 and R1 was transported out of the facility and has not returned. Both of R1 Conservator and Service Coordinator reported to Administrator R1 will not be returning to the facility due to having a broken hip and rehab and subsequently will be needing a higher level of care. R1s P&I funds have been transferred back to the conservator. Administrator states R1s leftover medications have been recorded and disposed at the medication disposal dispenser at Kaiser on Bruceville Rd.
According to staff interview and resident file review, no deficiencies are issued at this time however at the time of the case management visit, the issuance of a Civil Penalty was still being determined and the licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(1).

Per California Code of Regulations (CCR), Title 22, no deficiencies were observed during the visit. An exit interview was held with Administrator Shirley, and copy of the report was provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC809 (FAS) - (06/04)

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