197605258-2-8-2024-31-AS-TCAS-D29UHV-20240208143633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197605258
Report Date: 02/08/2024
Date Signed: 02/08/2024 02:38:14 PM

Document Has Been Signed on 02/08/2024 02:38 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
WOODLAND HILLS S.ASC, 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: 5	DATE:	02/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Suzete Tamayo		TIME COMPLETED:	02:30 PM

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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility at 11:30pm to conduct Annual inspection. LPA was greeted by Administrator Suzete Tamayo who allowed LPA to enter. There was (1) additional staff, and residents at the kitchen table eating lunch. Today's current census was (5). Facility license/sketch, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, infection control procedures,and Ombudsman poster, was visibly posted. Administrator certificate current and valid until July 21, 2024.

A physical plant tour of the facility inside and outside was conducted with Administrator. The following common areas: living, dining, kitchen, resident bedrooms, and bathrooms were inspected to ensure the facility was in compliance with Title 22 Regulations:

Kitchen: LPA observed a Licensing requirement of (7) day nonperishable, and (2) perishable, with (2) extra refrigerator stocked with food located in the garage. Food was labeled and properly stored in a healthy manner. Appliances were functional, clean, and in good repair. Chemicals, medication, household supplies, and knives, were secured and unlocked in the garage and kitchen area. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has (5) bedrooms, with (1) shared room. All bedrooms were properly furnished and supplied with appropriate bedding and linens. Rooms observed to have bedspreads, sheets, pillowcase, mattress pad, and blankets, and were in good repair. There are sufficient linens and towels observed. Bathrooms: There are (2); all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured at 105.8. degrees Fahrenheit. Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. There was no swimming pools or other bodies of water. There is outside furniture located in the front and back of the facility for resident's use. Smoke alarms and carbon monoxide detectors were tested and operating properly. Gates were unlocked and easily accessible.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JENNIFER HOME	FACILITY NUMBER: 197605258
	VISIT DATE: 02/08/2024

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Fire extinguisher fully charged. First aid kit furnished fully equipped. All exit doors have alarms; all were operating.

Record review: A complete record review of staff and residents were conducted; no errors observed. All Licensing documents observed in files. Training was current and update.

Medication review: No errors observed; facility in compliance.

Exit interview and copy of report provided.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC809 (FAS) - (06/04)

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