197609365-6-28-2021-31-AS-RVAA-C4EQ46-20210628114950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609365
Report Date: 06/28/2021
Date Signed: 06/28/2021 11:57:25 AM

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:	JMS HOME FOR SENIOR		FACILITY NUMBER:	197609365
ADMINISTRATOR:	OLILA, MADONNA M		FACILITY TYPE:	740
ADDRESS:	11447 YOLANDA AVE		TELEPHONE:	(747) 300-9059
CITY:	PORTER RANCH	STATE: CA	ZIP CODE:	91326
CAPACITY:	6	CENSUS: 5	DATE:	06/28/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Madonna Olila, Administrator		TIME COMPLETED:	11:30 AM

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) Rosaura Valenzuela conducted an unannounced Required One (1) year-Infection Control inspection to the facility. LPA met with Administrator Madonna Olila and explained the reason for the visit. A tour of the physical plant was conducted at 9:40am and the following was noted: There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet and hand sanitizer are available. LPA was screened upon entry. The facility had submitted and approved Mitigation 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. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has four (4) bedrooms and three (3) bathrooms currently occupying five (5) residents. Two (2) rooms are shared rooms and two (2) rooms are private rooms. (continued on LIC 809-C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

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: JMS HOME FOR SENIOR	FACILITY NUMBER: 197609365
	VISIT DATE: 06/28/2021

NARRATIVE

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Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 76 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector in the facility. Fire extinguisher is located by the kitchen and was purchased in 02/21.

The backyard of the facility has outdoor furniture with a covered shaded area for residents. There is no body of water at the facility. There is also a garage that is being used as a used equipment storage.

Laundry area is located inside the garage which were observed to be locked.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the shower and toilet. The hot water temperature was measured at 107.6 degrees. There was enough clean linen available the laundry room.

Medications-LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. There was one ( 1) complete first aid kit located above one of the kitchen cabinets.

Exit interview conducted. A copy of this report was issued and signature obtained.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021

LIC809 (FAS) - (06/04)

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