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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605266
Report Date: 09/16/2021
Date Signed: 09/16/2021 04:40:00 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:JMJ GUEST HOMEFACILITY NUMBER:
197605266
ADMINISTRATOR:LUCIA DELA REAFACILITY TYPE:
740
ADDRESS:43905 ELM AVENUETELEPHONE:
(661) 940-5550
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 6DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Lucia Dela ReaTIME COMPLETED:
04:00 PM
NARRATIVE
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LPA Melissa Spaeth, LPA Eleza Jackson and LPM Cassandra Harris conducted an unannounced annual visit to the facility at 10:05 am. Upon approaching the facility, LPAs observed the COVID signs on the door. LPAs and LPM were greeted by caregiver, Restituto (Rusty) Ebora and explained the purpose of the visit. LPA Spaeth observed caregiver was wearing a mask. Caregiver called Administrator Lucia Dela Rea and Administrator arrived to the facility at 10:15 am. LPAs' and LPM's temperature was taken upon entry and recorded. LPA Spaeth observed a thermometer, hand sanitizer, PPE masks, and sign in sheet at the front door.

The LPA's and LPM began tour at 10:20 am. LPA Spaeth observed two residents in the family room watching television. LPAs and LPM observed the four resident rooms. All rooms contained the necessary regulation requirements which include lamp, nightstand, chair and other items needed for the comfort of the residents.

LPAs observed the three bathrooms contained the required wash your hands sign, hand soap, paper towels, and trash cans in each bathroom. All parties then were escorted to the garage and LPA observed a refrigerator which contained fresh vegetables, frozen meats and vegetables, canned goods, PPE supplies such as face shields, surgical gowns, and gloves. Administrator unlocked a cabinet which contained hygiene items for residents.
Upon entering the kitchen, LPA observed an adequate supply of canned goods in the pantry, fresh fruits, fresh vegetables, dairy products in the refrigerator. The frozen section of the refrigerator contained frozen meats and vegetables. LPA Spaeth observed the knives were locked in a kitchen drawer and cleaning supplies were locked under the kitchen sink.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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: JMJ GUEST HOME
FACILITY NUMBER: 197605266
VISIT DATE: 09/16/2021
NARRATIVE
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At 10:17 am, LPAs and LPM observed the staff room which was not locked. LPAs observed the caregiver was not in the room and saw a bottle of rubbing alcohol and a bottle of medication was sitting in the room. LPAs informed Administrator that the staff room should be locked at all times. The staff room was locked by Caregiver at 10:30 am.

At 10:25 am LPAs entered a bathroom which residents will use the toilet and sink when needed. LPA Spaeth tested the water temperature and recorded the temperature was 136.5 F. LPA stated to Administrator the water temperature should be between 105 to 120 degrees F. LPA Spaeth stated to Administrator best practice would be to check the water temperature each week. Administrator stated will make sure the water temperature will be checked each week. Also LPA Spaeth observed the shower did not contain a slip resistant mat. At 2:20 pm Administrator purcahsed non slip mats and added to the bathroom.

LPAs and LPM were then escorted to the garage and observed the Caregiver took a key off a nail on the wall to open the garage. Upon entering the garage, LPA observed laundry detergent was not locked within the garage. LPA Spaeth explained the key should be stored in a secure area out of reach of the residents. LPA Spaeth also explained since there are two dementia residents living the facility, the keys need to be stored in a secure location. Administrator then removed the key from the wall.

At 10:47 am LPAs and LPM observed the staff and resident files were stored in an unlocked cabinet in the dining room. LPA Spaeth stated to Administrator that all records must be locked and secure. Also, LPAs observed the medication cabinet was not locked. LPA's reminded Administrator medication cabinet should be locked when not in use. At 11: 44 am, LPA Jackson reviewed resident files and observed there were two hospice care plans for R1 and R2. Postural support documentation was missing for R3 through R6.

Under Title 22 General Regulations, the following citations were issued and recorded on LIC 809D.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: JMJ GUEST HOME
FACILITY NUMBER: 197605266
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2021
Section Cited

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87303 Maintenance & Operation (a) The facility shall be clean, safe, sanitary . at all times. Maintenance shall include..maintenance services & procedures for the safety and well-being of residents, ....
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This was not met based upon: LPA Spaeth observed the key to the garage was accessible to residents, which contained cleaning supplies. Also, the staff room was unlocked and contained medications and rubbing alcohol.
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Type A
09/27/2021
Section Cited

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87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing .. records and for safeguarding the confidentiality of their contents.
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This was not met based upon: LPA Spaeth observed the file cabinet which contained resident records was not locked.
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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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: JMJ GUEST HOME
FACILITY NUMBER: 197605266
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2021
Section Cited

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Faucets used by residents for personal care ...shall deliver hot water. Hot water temperature controls shall be ...automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F .. and not more than 120 degree F ...
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This was not met based upon: At 10:25 am, LPA Spaeth tested the water temperature in bathroom one which read 136.5
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Type A
09/27/2021
Section Cited

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87633 Hospice Care of Terminally Ill Residents (4) A written hospice care plan which specifies the care, services, and necessary medical intervention .. to supplement the care & supervision provided ...is developed for .. resident .. by that resident’s hospice agency & agreed to by the licensee and the resident, .. if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).
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This is based upon: LPA Jackson reviewed the resident files and observed the hospice plan was missing from the file.
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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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4