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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609365
Report Date: 03/03/2025
Date Signed: 03/03/2025 03:07:10 PM

Document Has Been Signed on 03/03/2025 03:07 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:JMS HOME FOR SENIORFACILITY NUMBER:
197609365
ADMINISTRATOR/
DIRECTOR:		OLILA, MADONNA MFACILITY TYPE:
740
ADDRESS:11447 YOLANDA AVETELEPHONE:
(747) 300-9059
CITY:PORTER RANCHSTATE: CAZIP CODE:
91326
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
03/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Lydia Olila- Administrator DesigneeTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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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 10:45 am, with the assistance of Staff#2 (S2), LPA took a tour of the physical plant. Required postings were observed in the entry area. The fire extinguisher is located in the dining area. The purchase date is March 3, 2025. LPA tested the smoke alarms and found that they function properly. The carbon monoxide detector was tested, and it 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 and with sufficient lighting.
Bathrooms: There are three (3) bathrooms designated for residents' use. All three bathrooms were properly supplied and had functional fixtures. The hot water temperature from the bathroom sink was measured at 112.3 and 113.8 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: The Laundry door is locked, and thus, chemical hazards are inaccessible to residents. Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. LPA observed that R2 has no updated Physician Report. R3 has an incomplete physician Report. LPA also observed that there's no hospice care plan for R4, indicating the need for the full rails. LPA observed R1, R2, and R3 have 1/2 bed rail without physician order.
(Continue on 809 C)
Eva MillerTELEPHONE: (818) 596-4373
Mariana AgbanTELEPHONE: 818-738-4525
DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: JMS HOME FOR SENIOR
FACILITY NUMBER: 197609365
VISIT DATE: 03/03/2025
NARRATIVE
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Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and in compliance with licensing forms. LPA observed that there's no physical file for the Administrator. Medications: Medication and Medication Records were reviewed for proper documentation.

Exit Interview conducted, citations issued, appeal rights given, and copy of this report signed and delivered.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/03/2025 03:07 PM - It Cannot Be Edited


Created By: Mariana Agban On 03/03/2025 at 01:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observations and record review the licensee did not comply with the section cited above. LPA observed that there's no hospice care plan for R4, indicating the need for the full rails. LPA also observed R1, R2, and R3 have 1/2 bed rail without physician order. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2025
Plan of Correction
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Licensee/Administrator will request a current and updated hospice care plan for R4 and which indicates the need for the full rails. Administrator will provide copy of physicians order for R1, R2, and R3 to have 1/2 bed rail. Copy of the Hospice care plan for R4 and physician orders for R1, R2, and R3 will be submitted as POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Eva Miller
TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME:Mariana Agban
TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/03/2025 03:07 PM - It Cannot Be Edited


Created By: Mariana Agban On 03/03/2025 at 01:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(6)(A)
Personnel Records
(A) For administrators this shall include verification that he/she meets the educational requirements in Section 87405(d) through (g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Administrator has no physical file in the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2025
Plan of Correction
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Administrator will provide a copy of her employee file by the POC date.
Type B
Section Cited
CCR
87458(c)(1)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. R2 has no updated Physician Report. R3 has an incomplete physician Report. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2025
Plan of Correction
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Administrator will provide updated and complete phyiscian reports for R2 and R3 by the POC date.
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:Eva Miller
TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME:Mariana Agban
TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2025


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