197602074-10-18-2022-31-AS-APAA-CKBSZP-20221018141928

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602074
Report Date: 10/18/2022
Date Signed: 10/18/2022 02:20:45 PM

Document Has Been Signed on 10/18/2022 02:20 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	J & S HOME CARE II		FACILITY NUMBER:	197602074
ADMINISTRATOR:	SOFIA ALVAREZ		FACILITY TYPE:	740
ADDRESS:	9950 WILBUR AVENUE		TELEPHONE:	(818) 886-4286
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 6	DATE:	10/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Sofia Alvarez, Administrator		TIME COMPLETED:	02:50 PM

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Licensing Program Analyst (LPA) Angela Panushkina conducted a required annual visit to this facility. LPA met with the staff member, Nenita Santillan, who granted access to the facility and then contacted the Administrator. Administrator arrived shortly after and LPA explained the reason for the visit.

Infection Control: Upon arrival, LPA observed two (2) out of two (2) staff members wearing proper face masks.

Kitchen: At approximately, 1:15pm LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

Medications: At approximately, 1:25pm LPA observed medications are centrally stored and locked in the cabinet, by the kitchen area and inaccessible to residents in care.

Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Bathrooms: At 1:40pm LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 120.0°F. LPA observed appropriate grab bar and had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Common Areas: The facility maintains a comfortable temperature at 77°F. The living room and dining area

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: J & S HOME CARE II	FACILITY NUMBER: 197602074
	VISIT DATE: 10/18/2022

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appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. The fire extinguisher is located in a living room, by the kitchen and was purchased on 10/18/22.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and carbon monoxide was located in a hallway. At 1:55pm they were tested and observed to be operational.

Outside areas: At approximately, 2:00pm LPAs toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

The garage: The garage is used for a storage (PPE, extra equipment, furniture, food, etc.) and was observed locked and inaccessible to residents in care.

Laundry: Laundry area is located by the staff (live-in) room and was also observed to be locked.

Administrative: Administrator will email a copy of LIC500 and Certificate of Liability Insurance to LPA

No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC809 (FAS) - (06/04)

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