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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609853
Report Date: 04/26/2024
Date Signed: 04/26/2024 04:16:32 PM


Document Has Been Signed on 04/26/2024 04:16 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:REESEJOY CARE HOME IIFACILITY NUMBER:
197609853
ADMINISTRATOR:RAMIREZ, ROBERTOFACILITY TYPE:
740
ADDRESS:17544 SAN JOSE STTELEPHONE:
(805) 832-8792
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 5DATE:
04/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Raynaldo Reyes- StaffTIME COMPLETED:
04:30 PM
NARRATIVE
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In conjunction to the complaint number 31-AS-20210519164840 Licensing Program Analysts (LPAs) Mariana Agban and Michael Cava conducted a case management- Deficiencies visit.

During the complaint investigation, LPAs conducted medication and Medication Records review for proper documentation for three (3) out 5 residents. LPAs could not complete an accurate medication count due to incomplete medication forms. LPAs also observed insufficient food, within for a total of 5 residents in care. On 04/11/2024 Interviews with 2 out of 5 residents revealed that there's no variety of food and that it's only based on Filipino cuisine. LPA Agban had issued Advisory Notes - Technical Assistance regarding food variety. LPA Agban had advised Administrator that meals shall consist an appropriate variety of foods. On today's visit interviews with 3 out 5 residents confirmed that staff don't offer variety of food.

Exit Interview Conducted. Deficiencies Cited. Report Issued
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
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 3


Document Has Been Signed on 04/26/2024 04:16 PM - It Cannot Be Edited

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: REESEJOY CARE HOME II
FACILITY NUMBER: 197609853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2024
Section Cited
CCR
85076(d)(1)

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85076 Food Service (d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premise.
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The licensee shall purchase sufficient food, a copy of receipt and photo documentation of sufficient food shall be submitted by the POC due date.
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This requirement is not met as evidence
Based on teams observations, insufficient food, within the regulation was observed for a total of five residents in care. This poses an immediate health, safety, or personal rights risk to clients in care.
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Type A
04/27/2024
Section Cited
CCR87465(a)(5)

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Incidential Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Within 24 hours, The licensee shall review 87465(a)(5) and submit a written memo of understanding to LPA by the POC date. The licensee will conducted training to address this section and submit proof of training to LPA by May 10, 2024.
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Based on medications review, the licensee did not comply with the section cited above, as the LPAs could not complete an accurate medication count, which poses an immediate health and safety risk to residents in care.
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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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/26/2024 04:16 PM - It Cannot Be Edited

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: REESEJOY CARE HOME II
FACILITY NUMBER: 197609853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2024
Section Cited
HSC
87555(b)(5)

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87555 GENERAL FOOD SERVICE REQUIREMENTS (b) (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. This requirement is not met as evidence
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Administrator will make new weekly menus to insure that there is a variety of food being served. Administrator will submit copies of menu to LPA by the POC date.
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Based on interviews, 3 out 5 residents confirmed that staff don't offer variety of food. This poses a potenital health, safety, or personal rights risk to clients in care.

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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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2024
LIC809 (FAS) - (06/04)
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