197606986-10-4-2023-31-AS-ADUA-CWAUXF-20231004155816

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606986
Report Date: 10/04/2023
Date Signed: 10/04/2023 03:58:29 PM

Document Has Been Signed on 10/04/2023 03:58 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:	JAY CARROLL DRIVE FAMILY CARE		FACILITY NUMBER:	197606986
ADMINISTRATOR:	JOCELYN RAMBUYAN		FACILITY TYPE:	740
ADDRESS:	20332 JAY CARROLL DRIVE		TELEPHONE:	(661) 360-9736
CITY:	SAUGUS	STATE: CA	ZIP CODE:	91350
CAPACITY:	6	CENSUS: 5	DATE:	10/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Jocelyn Rambuyan		TIME COMPLETED:	03:56 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 Jocelyn Rambuyan for a Required One (1) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 12:15pm and the following was noted: There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. The facility has enough PPE supplies. The facility has a total of five (05) bedrooms and two (02) bathrooms for both residents and staff. The facility is fire cleared for six (06) non-ambulatory, six (06) bedridden and a hospice waiver for three (03). The facility is currently occupying five (05) residents of which two (02) are under hospice care. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The living and dining rooms are neat and clean with appropriate furniture. The facility maintains a comfortable temperature at 77°F. Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher observed to be full and last inspected on 11/17/2022. (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: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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: JAY CARROLL DRIVE FAMILY CARE	FACILITY NUMBER: 197606986
	VISIT DATE: 10/04/2023

NARRATIVE

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The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit.

Residents 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 110.8°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. Laundry detergents, cleaning agents and other toxins are locked away.

LPA observed medication and first aid kit to be locked and inaccessible to residents.

No health and safety hazards noted during the visit.

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: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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