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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608294
Report Date: 10/01/2025
Date Signed: 10/01/2025 04:14:20 PM

Document Has Been Signed on 10/01/2025 04:14 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:J.R. RETIREMENT HOME FOR ELDERLYFACILITY NUMBER:
197608294
ADMINISTRATOR/
DIRECTOR:		JEFFERSON L. REYESFACILITY TYPE:
740
ADDRESS:44035 22ND STREET WESTTELEPHONE:
(661) 951-0994
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 5DATE:
10/01/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jefferson Reyes, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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At 2:00 PM, Licensing Program Analyst (LPA) Huma Rahimi arrived at the facility above to conduct an annual required visit. LPA was greeted and granted access by staff #1 (S1) EDMIN Bernalledezma. S1 contacted the administrator Jefferson Reyes and informed them LPA was at the facility. LPA explained the reason for the visit. LPA and the Administrator conducted a physical plant tour of the facility and observed the following:

Kitchen: The kitchen was observed clean with sufficient supply of two-day perishables and seven-day non-perishables foods. LPA observed the knives and sharp objects located in a locked kitchen cabinet inaccessible to residents in care.

Bedrooms: LPA toured four (4) resident bedrooms. Two (2) bedroom may be shared. LPA observed rooms to have appropriate bedding and lighting. There is a night stand and sufficient storage. LPA tested the auditory alarms on the exit doors in the bedrooms and they were observed operational.


Bathrooms: LPA toured two resident bathrooms. One (1) bathroom is located in a shared bedroom for private use. All bathrooms were observed with non-skid matts, grab bars, toilet paper, paper towels and hand soap. Hot water temperature was tested at 2:25 PM, and measured at 119.3°F, within regulation. (Continued to LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: J.R. RETIREMENT HOME FOR ELDERLY
FACILITY NUMBER: 197608294
VISIT DATE: 10/01/2025
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Common Areas: These include living area and dining area. Areas were observed clean and clear of clutter. The facility maintains a comfortable temperature at 76°F. There is a fire place that was adequately screened. There are (2) carbon monoxide detector one (1) in the kitchen and one (1) living area. LPA tested carbon monoxide detector by the living area and observed it operational. There is one fire extinguisher observed fully charged with purchase date 09/26/2025. Auditory alarm on the sliding door leading to the backyard was observed functional.
Laundry/Garage: LPA observed chemicals/hazardous items in a locked cabinet in the laundry room inaccessible to residents in care. The laundry room leads to the attached garage that is used to store extra food in a deep freezer and for storage.

Outside: LPA toured the outside area of the facility and observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Between 2:30 PM to 3:15 PM, LPA reviewed records of five (5) residents and two (2) staff. Residents and staff records appeared to be complete and updated.

At 3:16 PM, Administrator tested smoke detectors located throughout the facility. LPA observed smoke detectors to be functioning properly.

Medications: At approximately 3:25 PM. LPA reviewed Medication and Medication Records. LPA observed medications locked in a kitchen cabinet. Medications were reviewed for proper storage and documentation. Facility also uses a Medication Administration Record (MAR). LPA conducted a random review of medication for Resident #3 (R3) and observed that the bottle of Clonazepam 1MG started on 04/08/2025 (to present 541 days) with one hundred (100) tablets and the bottle (take one tablet daily) still had twenty three (23) tablets remaining. The Administrator stated that R3 refuses to take medication sometimes; however, no incident report was submitted to the Community Care Licensing nor R3's physician or family was notified.

Deficiencies issued during today's visit. Exit interview conducted. Copy of the report provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Huma Rahimi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/01/2025 04:14 PM - It Cannot Be Edited


Created By: Huma Rahimi On 10/01/2025 at 03:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: J.R. RETIREMENT HOME FOR ELDERLY
FACILITY NUMBER: 197608294

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(2)

87465- Incidental Medical and Dental Care:
c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (observation) (interview) (record review)], the licensee did not comply with the section cited above in
not assuring that R3's prescribed medications were given as prescribed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/03/2025
Plan of Correction
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Administrator agreed to schedule vendorized training for all staff by 10/03/2025 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion. Administrator also agreed to notify doctor and submit LIC 624 to CCL regarding the incident.
Type B
Section Cited
CCR
87211(a)(1)A,B&D
Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)...


This requirement is not met as evidenced by:
Deficient Practice Statement
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Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R3's incident report for medication refusal shall be submitted to LPA by POC date. Administrator will notify R3’s Physician and family as well.
POC Due Date: 10/03/2025
Plan of Correction
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Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R3's medication refusal from 04/08/2025 to current, which poses a potential health and safety risk to persons in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:
Huma Rahimi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2025


LIC809 (FAS) - (06/04)
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