197609713-6-9-2022-31-AS-TSMH-CF8URD-20220609154835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609713
Report Date: 06/09/2022
Date Signed: 06/09/2022 03:48:44 PM

Document Has Been Signed on 06/09/2022 03:48 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 RESIDENTIAL CARE		FACILITY NUMBER:	197609713
ADMINISTRATOR:	OLILA, MADONNA		FACILITY TYPE:	740
ADDRESS:	15346 MAYALL ST		TELEPHONE:	(818) 920-2995
CITY:	MISSION HILLS	STATE: CA	ZIP CODE:	91345
CAPACITY:	6	CENSUS: 6	DATE:	06/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	MADONNA OLILA		TIME COMPLETED:	03:55 PM

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) Tihesha “Lynn” Smith conducted an unannounced annual/infection control visit to this facility at 12:30 pm and observed COVID signs on the front door. LPA was greeted by caregiver Elmer Urieta and temperature was taken and recorded at sign in station in living room to the right of main door. The administrator was called and arrived at 1:10 pm. LPA observed that the five (5) clients were at the facility during visit. LPA conducted a tour of the physical plant at 1:30 pm to ensure there are no health and safety hazards and facility staff are following Title 22 Regulations and the following was noted: Hand washing, coughing etiquette, physical distancing, and other necessary signs were posted in the bathroom and all over the facility. The facility has six (6) bedrooms: five (5) bedrooms for clients and (1) one bedroom designated as staff room. There is a half bathroom (toilet only) near laundry area and three (3) bathrooms:(1) near bedrooms #1 and # 2 (Jack and Jill style) and two (2) bathrooms in hallway near bedrooms # 4 and #5. There is no body water in the facility. Bedrooms All bathrooms were clean, properly supplied and had functional fixtures. Linen storage was also checked and observed to have sufficient supply of clean linen and towels. Bathrooms were observed to be clean and sanitary with sufficient supplies. Hot water temperature range between 105 and 120-degrees Fahrenheit. Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean on today’s visit. Living/dining room was observed to be clean and furniture in good condition and adequate seating (Cont. on 809)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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 RESIDENTIAL CARE	FACILITY NUMBER: 197609713
	VISIT DATE: 06/09/2022

NARRATIVE

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(Cont. form 809)

for clients. Kitchen area was observed to be clean. Laundry area is adjacent to kitchen and observed to be clean and appliances in good repair. All cleaning supplies are locked in pantry closet across from laundry area in addition to hygiene supplies and a sufficient supply of PPE's.

Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable. Readywise emergency food supply stored on top of staff refrigerator and canned foods stored in kitchen cabinets. Additional water stored near staff outdoor area. Sharps are locked under kitchen sink.

Medication are located in kitchen and stored in upper locked cabinets with fully stocked first aid kit.

Temperature of facility observed and set to 78 degrees Fahrenheit.
Fire extinguisher There is one (1) fire extinguisher in the facility located in the kitchen near medication cabinet. Extinguisher were observed to be charged with receipt dated: 3/29/2022. Dual Smoke alarms and carbon monoxide are hardwired and interconnected, were tested and observed to be functioning.
The facility does not have a garage only car ports. There are two (2) patio areas in the backyard: One covered by attached pergola and one shaded by a large guava tree for clients use. Both areas observed to be clean and furnished with adequate seating. There is a separate area for staff located within the vicinity. The area has private bathroom and observed to be locked and inaccessible to client during the visit.

The grounds entry/exits area were clean with and free of obstruction.

There was no immediate health and safety hazard observed during the day of inspection. There are no deficiencies to report.

Exit interview conducted and a copy of this report was given.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC809 (FAS) - (06/04)

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