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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605266
Report Date: 10/06/2022
Date Signed: 10/06/2022 04:15:48 PM


Document Has Been Signed on 10/06/2022 04:15 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: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: 4DATE:
10/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:LUCIA DELA REATIME COMPLETED:
03:00 PM
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LPA Spaeth conducted an unannounced annual visit to the facility at 1:45 pm. Upon approaching the facility, LPA observed the COVID signs on the door. LPA was greeted by caregiver who was wearing a mask and LPA stated the purpose of the visit. Caregiver confirmed there are four residents within the facility. LPA's temperature was taken and LPA answered the COVID questions at the sign in station. LPA observed thermometer, hand sanitizer and sign in sheet at the sign in station. The Administrator arrived at 2:10 pm.

LPA and Administrator began tour at 2:10 pm. LPA Spaeth observed a resident in the living room watching television. LPA observed the living room contained comfortable seating. The dining room contained dining room table and dining chairs. The kitchen was clean. LPA observed the refrigerator was stocked with a two-day supply of fresh fruits and vegetables. The pantry was stocked with a seven-day supply of canned good items. LPA observed the knives were locked in a drawer and the cleaning supplies were locked underneath the sink. The kitchen sink area contained wash your hands sign, hand soap, and a trash can. The medications were locked in the kitchen. LPA observed the resident's bedrooms contained bed, linens, lamp, night stand, and chest of drawers. All rooms were neat and clean. LPA also observed two residents taking a nap in the resident's room.

LPAs observed the two bathrooms contained the required wash your hands sign, hand soap, paper towels, and trash cans in each bathroom. LPA was then 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. The backyard contained a shaded area with comfortable seating. The side gate that leads from the backyard to the front yard was not locked.

There are no deficiencies to report at this time. Exit interview was conducted, appeal rights discussed, and a copy of the report was given to the Administrator.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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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