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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603061
Report Date: 12/11/2024
Date Signed: 12/11/2024 03:59:02 PM

Document Has Been Signed on 12/11/2024 03:59 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:J & S HOME CARE IIIFACILITY NUMBER:
197603061
ADMINISTRATOR/
DIRECTOR:
ALVAREZ, JOSEFACILITY TYPE:
740
ADDRESS:18534 CHATSWORTH STTELEPHONE:
(818) 363-3651
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Sofia AlvarezTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff and explained the reason for the visit. Administrator Sofia Alvarez arrived shortly after. At approximately 10:20 a.m., with the administrator's assistance, LPA took a tour of the physical plant, and the following was observed: Required postings were observed in the entry area.
Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. The smoke alarms are hardwired and function properly—the carbon monoxide detector functions properly and located in the kitchen.
Bedrooms: There were four (4) bedrooms designated for residents' use. Two (2) bedrooms are designated for private use, and two (2) rooms are shared. All four bedrooms, in use by residents, were properly furnished with appropriate bedding and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 110.3 and 108.6 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection.
Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. The dining room table is large enough to sit the capacity of the facility. Seating such as couches were in good repair and sat the capacity of the facility. There is a fireplace properly secured with a screen. Common areas observed furnished appropriately. LPA observed a sufficient supply of linens, toiletries, and back stock in three (3) hallway closets Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards. There is a swimming pool that is fenced all around its parameters. The fence was at least five feet high with a gate, that is also five feet high. The gate was observed locked, making it inaccessible for residents to enter.
(Continue on 809C)
Eva MillerTELEPHONE: (818) 596-4373
Mariana AgbanTELEPHONE: 818-738-4525
DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: J & S HOME CARE III
FACILITY NUMBER: 197603061
VISIT DATE: 12/11/2024
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The laundry area is located on the covered carport and the appliances are observed to be functional. Toxins stored and locked in the staff room were observed to be inaccessible to residents
Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were reviewed for proper documentation.

Temperature: The facility maintains a comfortable temperature of 78 degrees Fahrenheit


Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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