<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608294
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:52:23 PM


Document Has Been Signed on 10/27/2022 02:52 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:J.R. RETIREMENT HOME FOR ELDERLYFACILITY NUMBER:
197608294
ADMINISTRATOR:JEFFERSON L. REYESFACILITY TYPE:
740
ADDRESS:44035 22ND STREET WESTTELEPHONE:
(661) 951-0994
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 4DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Roger Remorozo - designeeTIME COMPLETED:
01:45 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
On 10/27/22 Licensing program analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection. Upon arrival LPA was greeted by staff and LPA later met with designee Roger Remorozo. The purpose of the visit was explained.

LPA conducted a tour of the physical plant. LPA was able to tour the home and did not observe any immediate health and safety concerns. Covid infection control signage is located throughout the facility. Facility consists of 4 bedrooms, 2 bathrooms. Fire alarm and carbon monoxide alarm appear to be functional. Fire extinguisher has a purchase date of 10/13/22. LPA observed there to be sufficient stock of one-week non-perishable foods and two day perishable foods. Bathrooms were toured and LPA observed the necessary toiletries. There are hand sanitizing stations throughout the facility. Staff were observed wearing masks. Bedrooms are appropriately furnished and have appropriate lighting. Facility maintains a temperature of 76 degrees F. There is a designated office area where medications are stored and are kept inaccessible to residents in care. There is a designated laundry area that leads to the garage. Garage is used as a storage area and consists of two (2) bedrooms designated for staff use. Facility maintains sufficient PPE for more than 30 days. Chemicals are stored in the laundry area.

No deficiencies issued. Exit interview conducted. Report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2022
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 1