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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004688
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:51:58 PM


Document Has Been Signed on 03/10/2022 12:51 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 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: 5DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Jimmy Jones - Licensee/AdministratorTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted a unannounced Required 1- year Annual Inspection. LPA met with Licensee and explained the purpose of today’s inspection.

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 expires on August 13, 2022. First aid kit was observed to be complete. Fire drill was last conducted on 06/15/2021. LPA observed mitigation plan complete. There are five residents, two are on hospice care.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL via email to LPA by May 10, 2022:
Control of Property or Lease, Facility Program/Plan of Operation- Food Services/Activities/AWOL Procedures/Neighborhood Complaint Procedures/Elopement Procedure

No deficiencies cited during inspection. Exit interview conducted with Licensee and a copy of report given.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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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