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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609365
Report Date: 03/01/2024
Date Signed: 03/07/2024 11:59:28 AM


Document Has Been Signed on 03/07/2024 11:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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: 6DATE:
03/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Lydia Olila- Administrator DesigneeTIME COMPLETED:
11:45 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) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with Administrator Designee Lydia Olila and explained the reason for the visit. At approximately 8:45 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The fire extinguisher is located in the dinning area. The purchase date is March 1, 2024. LPA tested The smoke alarms were tested and function properly. The carbon monoxide detector was tested and functions properly. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There were four (4) bedrooms designated for residents' use. Two (2) bedrooms are designated for private use, and two (2) rooms are shared. All four bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting.Bathrooms: There are three (3) bathrooms designated for residents' use. All three bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 110.4 and 109.9 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection.
Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry room: Laundry door is locked and thus chemical hazards are inaccessible to residents. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: Medication and Medication Records were review for proper documentation.Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024
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