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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609713
Report Date: 07/07/2024
Date Signed: 07/07/2024 03:42:32 PM


Document Has Been Signed on 07/07/2024 03:42 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:JMS RESIDENTIAL CAREFACILITY NUMBER:
197609713
ADMINISTRATOR:OLILA, MADONNAFACILITY TYPE:
740
ADDRESS:15346 MAYALL STTELEPHONE:
(818) 920-2995
CITY:MISSION HILLSSTATE: CAZIP CODE:
91345
CAPACITY:6CENSUS: 4DATE:
07/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Nora Rosales - StaffTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced visit at this facility for a One (1) year Required visit. LPA met with staff Nora Rosales who called the administrator Madonna Olila and explained the purpose of the visit. Ms. Olila designated Ms. Rosales to sign the report.

A tour of the physical plant was conducted at 12:32 PM. The facility has six (6) bedrooms and four (4) bathrooms currently occupying four (4) residents on four (4) private rooms and one (1) shared room. One (1) bedroom and one (1) bathroom is designated for the staff. The facility fire cleared for six (6) non-ambulatory residents, one of which may be bedridden in Room #1. Hospice waiver for two (2) residents.

There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation plan and Infection plan.

Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted:

Living and dining room furniture were also checked. The living room is neat and clean along with the family room. The facility maintains a comfortable temperature at 75°F. The carbon monoxide and smoke detector are tested and observed to be operational. Smoke detectors are hardwired and interconnected. Fire extinguisher was observed to be full and last bought on 06/20/24.

The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water at the facility.

(continued on LIC 809-C)
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2024
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: JMS RESIDENTIAL CARE
FACILITY NUMBER: 197609713
VISIT DATE: 07/07/2024
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(continued from 809-C)

There is a two (2) car port located at the back of the facility. There is a detached separate house at the vicinity which is currently being used as a storage and staff rest area. The house was locked during visit.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, pesticides and other toxins are stored in a kitchen cabinet and observed to be locked and inaccessible to residents.



The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene products on each bathroom which is provided by the licensee.

Staff Rooms: Staff rooms are locked. No medications are observed in the staff room.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The sink on the bathroom in between Rooms #1 and 2 has a leak. The hot water temperature measured at a range of 105.9°F to 111.2°F. There is sufficient supply of clean linen available in stock at the cabinet.

Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. Complete first aid kit is readily available.

Client records: Client records are reviewed. Client records appear to be complete and updated.
Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. Disaster drill was last conducted on 06/20/24. Required posting observed in facility (complaint hot line poster).

Exit interview conducted and copy of this report issued.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2024
LIC809 (FAS) - (06/04)
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