197607020-10-15-2023-31-AS-JGTN-CWMQ7M-20231015115523

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607020
Report Date: 10/15/2023
Date Signed: 10/15/2023 11:55:46 AM

Document Has Been Signed on 10/15/2023 11:55 AM - 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:	JOE-SEPHINE RESIDENTIAL CARE FAC. FOR THE ELDERLY		FACILITY NUMBER:	197607020
ADMINISTRATOR:	JOSEPHINE C. SANOY		FACILITY TYPE:	740
ADDRESS:	615 CURVE CIRCLE		TELEPHONE:	(661) 942-4307
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	4	CENSUS: 3	DATE:	10/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Josephine Sanoy - Administrator		TIME COMPLETED:	12:00 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) Gary Tan conducted an unannounced one (1) year Required visit at this facility. LPA was greeted by Administrator Josephine Sanoy and informed of the purpose of the visit. LPA observed two (2) residents watching TV the living room and one (1) was eating breakfast at the dining table A tour of the physical plant was conducted with the Administrator at 9:45 AM. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for three (3) non-ambulatory, one bedridden, and a hospice waiver for one resident. Infection control: The facility is following current infection control recommendations. The main door is the only entrance being utilized at this facility. The required poster are posted at the main door. Screening area is located immediately after entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. Food Inspection: LPA conducted a tour of the kitchen and observed that there are sufficient stock of both perishable and non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to residents in care. The medication cabinet was also observed to be locked. Cleaning supplies and chemicals were observed to be locked in the storage room.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2023

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

FACILITY NAME: JOE-SEPHINE RESIDENTIAL CARE FAC. FOR THE ELDERLY	FACILITY NUMBER: 197607020
	VISIT DATE: 10/15/2023

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(continued from LIC 809)

Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 73°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational. There is a fire extinguisher located in the living room. The Fire extinguisher was observed to be full and last serviced 6/24/23.

Garage/Laundry: LPA observed the garage to be attached to the facility and is currently being used for storage. LPA observed a refrigerator and deep freezer in the garage. The Laundry room is located in the garage. All chemicals/hazardous items were observed to be locked in a cabinet.

Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. All alarms on the exit doors are functional.

Bathrooms: LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested and measured at 118.1°F and within the range.

Physical environment: LPA observed a covered shaded area for residents. No bodies of water on the premises. LPA observed all tools in a locked gated area.

Staff and residents records were checked. Staff present has criminal record clearances and associated to this facility. Staff records appear to be complete and current. Client records were also reviewed and appeared to be complete and current.

Disaster drill was last conducted on 09/14/23. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2023

LIC809 (FAS) - (06/04)

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