197605258-11-10-2021-31-AS-ADUA-C8N3KH-20211110171911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197605258
Report Date: 11/10/2021
Date Signed: 11/10/2021 05:19:17 PM

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:	JENNIFER HOME		FACILITY NUMBER:	197605258
ADMINISTRATOR:	MARY JANE RAFANAN		FACILITY TYPE:	740
ADDRESS:	24401 JENNIFER PLACE		TELEPHONE:	(661) 254-7476
CITY:	NEWHALL	STATE: CA	ZIP CODE:	91321
CAPACITY:	6	CENSUS: 6	DATE:	11/10/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:04 PM
MET WITH:	Maxima Rafanan, Administrator		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Abeye Duguma met with the Administrator Maxima Rafanan for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 2:05pm and the following was noted: There is one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during the visit. Signs to wear a mask and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE in a storage cabinet in the kitchen and breakfast nook. The facility has six (06) bedrooms total of which five (05) are used for residents and two (02) bathroom for both residents and staff. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for one (01). The facility is currently occupying five (05) non-ambulatory residents. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The facility does not have a swimming pool/body of water. The garage is currently being used as laundry/storage room. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the garage. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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: JENNIFER HOME	FACILITY NUMBER: 197605258
	VISIT DATE: 11/10/2021

NARRATIVE

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Knives and sharps are observed to be locked in a kitchen drawer inaccessible to residents. Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 77°F. The smoke and carbon monoxide detectors are hardwired, not interconnected and observed to be operational. Administrator says they are checked monthly and maintains a log. Fire extinguishers are located in the kitchen and observed to be full and last inspected on 07/2021. Staff room was observed and located near the kitchen area. No medications are observed in the staff room. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lit. Clients have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 119.4°F. Towels and washcloths are not shared. There was enough clean linen available in the hallway cabinet. Medications: LPA observed medication cabinet to be locked and inaccessible to residents, located in the kitchen. There is a complete first aid kit located inside the cabinet at the end of the hallway.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

LIC809 (FAS) - (06/04)

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