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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197605258
Report Date: 08/25/2021
Date Signed: 08/25/2021 12:44:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/11/2021 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20210811113127
FACILITY NAME:JENNIFER HOMEFACILITY NUMBER:
197605258
ADMINISTRATOR:MARY JANE RAFANANFACILITY TYPE:
740
ADDRESS:24401 JENNIFER PLACETELEPHONE:
(661) 254-7476
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY:6CENSUS: 4DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility did not provide a comfortable temperature for residents
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) LaQueena Lacy conducted an unannounced initial 10-day complaint visit. LPA met with Maxima Rafanan the designated staff and explained the purpose for this visit.

Entrance interview conducted.

The concerns were addressed that the facility did not provide a comfortable temperature for residents. The department received evidence that on August 04, 2021 the facility temperature was 88 degrees F which was not within Title 22 Regulation.

To investigate the allegation, LPA conducted a physical plant tour at 10:10am. LPA observed the Facility’s thermostat at 83 degrees F. LPA tested the facility air temperature in the living room at 10:30am. The temperature measured 82.9 degrees F. At 10:47am and 11:15am LPA interviewed two (2) out of four (4) residents in care who indicated they were comfortable and fine with no complains about the temperature.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20210811113127
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JENNIFER HOME
FACILITY NUMBER: 197605258
VISIT DATE: 08/25/2021
NARRATIVE
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At 11:27am LPA spoke with the designated staff Maxima Rafanan and she admitted that on 08/04/2021, the facility temperature was 88 degrees F., due to the air conditioner not being turned on for the day.
Although today the facility temperature measured within acceptable range, based on evidence, and interviews the allegation is substantiated. No immediate health and safety hazard are noted during this visit.

Deficiency issued per Title 22 Regulation. Appeal rights and a copy of this report issued.

Exit interview conducted.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20210811113127
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: JENNIFER HOME
FACILITY NUMBER: 197605258
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2021
Section Cited
CCR
87303(b)(1)(2)
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A comfortable temperature for residents shall be maintained at all times. The facility shall heat rooms that residents occupy to a minimum of 68 degrees F, and …. cool rooms to a comfortable range, between 78 degrees F and 85 degrees F or in areas of extreme heat to 30 degrees F less than the outside temperature.
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At the time of this visit the facility maintained comfortable temperature. As per designated staff, on 08/04/2021, the Air Conditioner was not broken, it was turned off. The staff was advised to ensure that the facility temperature remains within acceptable range. Therefore, this citation was cleared during this visit.
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This requirement is not met as evidenced by; The licensee did not ensure that the temperature in the facility is within required range. On 08/04/21 the temperature was 88 degrees F. This poses a potential health and safety risk to residents in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3