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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004688
Report Date: 07/23/2021
Date Signed: 07/23/2021 03:30:58 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 CARE INC. IIFACILITY NUMBER:
347004688
ADMINISTRATOR:RUBY JONESFACILITY TYPE:
740
ADDRESS:8933 SHADY VISTA COURTTELEPHONE:
(916) 761-5204
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jimmy Jones, LicenseeTIME COMPLETED:
02:30 PM
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On 07/23/2021 at 11:30 am, Licensing Program Analyst (LPA) T. White spoke with Licensee, Jimmy Jones regarding facility risk assessment questions. Licensee confirmed no staff or clients have experienced symptoms within the last 10 days. At 1:00pm, LPA T. White arrived unannounced to conduct a required 1-year annual inspection. LPA met with Licensee and explained the purpose of today’s inspection. LPA was allowed entry into the facility that is licensed to serve a total capacity of 6 residents.

LPA 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 77 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 109 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 13, 2021. First aid kit was observed to be complete. Fire drill was last conducted on 06/15/2021. LPA observed mitigation plan complete.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 07/30/2021:
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan

No deficiencies cited during inspection. Exit interview conducted with Licensee and a copy of report given.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Treana WhiteTELEPHONE: (510) 566-9342
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
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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