197603061-11-28-2022-31-AS-TSMH-CLLRM9-20221128120821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603061
Report Date: 11/28/2022
Date Signed: 11/28/2022 12:08:35 PM

Document Has Been Signed on 11/28/2022 12:08 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 III		FACILITY NUMBER:	197603061
ADMINISTRATOR:	ALVAREZ, JOSE		FACILITY TYPE:	740
ADDRESS:	18534 CHATSWORTH ST		TELEPHONE:	(818) 363-3651
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91326
CAPACITY:	6	CENSUS: 5	DATE:	11/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Sofia Alvarez		TIME COMPLETED:	12:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced One (1) Year Required Infection Control visit for this facility at 10:30 am. LPA temperature checked upon entry and care staff disclosed administrator will arrive in approximately 10 minutes Administrators arrived at the facility at approximately 10:45 am and LPA disclosed the purpose of the visit.

LPA conducted a tour of the physical plant at 10:50 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The facility has a total of four (4) bedrooms and three (3) bathrooms with two (2) bathrooms designated for clients’ use. There is an additional room for staff use. Smoke detectors and Carbon Monoxide detector were tested and function properly. All exit alarms on doors were tested and were observed to function properly.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the five (5) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk, and eggs observed. The freezer is stocked with meats and frozen vegetables. Sharp objects are stored in a locked staff room. The clients’ medications and first aid kit are locked in cabinets under kitchen island and observed to be inaccessible to clients'.

The fire extinguisher is located in kitchen near medications attached to wall. Fire extinguisher observed to be charged.

Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each client. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathrooms: Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to (Cont to 809C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

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 III	FACILITY NUMBER: 197603061
	VISIT DATE: 11/28/2022

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(Cont. from 809)

ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 105.3- and 105.1-degrees Fahrenheit. Facility maintains a comfortable temperature for clients in care.

Common areas were observed for the ability to safely serve the needs of clients. These included the living room, family room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed furnished appropriately. LPA observed a sufficient supply of linens, toiletries and backstock in three (3) hallway closets.

Laundry area located on covered car port and appliances observed to be functional. Toxins stored and locked in staff room observed to be inaccessible to clients. An adequate supply of PPE’s stored in staff room.

There is a full pool and empty jacuzzi in the backyard. Both the pool and jacuzzi are fenced and observed to be locked and inaccessible to clients.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

Exit interview conducted and copy of report given.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC809 (FAS) - (06/04)

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