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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609365
Report Date: 01/21/2022
Date Signed: 01/21/2022 04:47:32 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/19/2022 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220119092000
FACILITY NAME:JMS HOME FOR SENIORFACILITY NUMBER:
197609365
ADMINISTRATOR:OLILA, MADONNA MFACILITY TYPE:
740
ADDRESS:11447 YOLANDA AVETELEPHONE:
(747) 300-9059
CITY:PORTER RANCHSTATE: CAZIP CODE:
91326
CAPACITY:6CENSUS: DATE:
01/21/2022
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility not following Covid-19 protocols
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Tihesha “Lynn” Smith conducted an unannounced 10-day complaint visit. LPA met with the Administrator Madonna Olila, and available designated staff Lydia and Arnel Olila and explained the purpose for this visit.
It was alleged that upon Credible Witness (CW)'s entry on August 10, 2021 and on January 05, 2022 staff are not wearing masks, are allowing guest to enter the facility without checking visitor’s temperature or asking covid-19 exposure related questions.
During today’s visit, at 10:40 Am LPA observed staff 1 (S1) putting on mask after answering the door. Staff 2 (S2) was not properly wearing mask as nose was exposed and mask covering only the mouth while interacting with residents. Temperature not checked on entry.
At the time of visit LPA Smith requested staff roster and Covid protocol at 12:30 PM and staff was unable to present current Covid protocol documents.
At 2:35pm LPA interviewed the Administrator and she admitted that staff was not following Covid 19 protocol.
Based on the information gathered during this visit there is sufficient information to support the allegation.



Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20220119092000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/21/2022
NARRATIVE
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(CONT FROM 9099)

Therefore, the allegation is deemed substantiated at this time.
Citation issued. Appeal rights discussed and given.
Exit interview conducted. Copy of this report issued
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220119092000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/21/2022
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities; (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by;
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Licensee will provide written Covid-19 protocol to LPA on 01/24/22. Licensee will ensure staff know what is required and are practicing Covid-19 protocol by providing training and signed communication from each staff member.
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Licensee did not assure that residents accorded with healthful accommodations.
Staff, working at the facility without wearing or properly wearing masks and not following Covid-19 entry protocols.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3