197609365-2-28-2022-31-AS-TSMH-CC44JB-20220228180827

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609365
Report Date: 02/28/2022
Date Signed: 02/28/2022 06:08:47 PM

Document Has Been Signed on 02/28/2022 06:08 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:	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: 4	DATE:	02/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Lydia Olila Cargiver		TIME COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced Required One (1) year-Infection Control inspection to the facility. LPA met with care giver Lydia Olila and explained the reason for the visit. Lydia revealed administrator out of country and not available.

A tour of the physical plant was conducted at 1:35 pm and the following was observed:

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 bathrooms and on message board.

Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 77 degrees. The smoke detectors are hardwired and interconnected and observed to be functional. There is a carbon monoxide detector in the facility and is functional. Fire extinguisher current (02/28/2022) with receipt attached.

Kitchen area clean and sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Ready America Packs located on top of refrigerator. Sharps are stored in a locked drawer.

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

Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

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: 02/28/2022

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(Cont fro 809)

Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. LPA measured the hot water between the required limit of 105-120 degrees Fahrenheit during time of visit.

Laundry area is located inside the garage which were observed to be locked. There was enough clean linen available in the laundry room.

The backyard of the facility has outdoor furniture with a covered shaded area for residents. The garage at the facility is used to store equipment. The facility has sufficient stock of PPE in the storage room.

Exit interview conducted. A copy of this report emailed.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

LIC809 (FAS) - (06/04)

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