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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610105
Report Date: 11/26/2023
Date Signed: 11/26/2023 12:11:29 PM

Document Has Been Signed on 11/26/2023 12:11 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:MELONIE & JESSIE JAMES JR. ARFFACILITY NUMBER:
197610105
ADMINISTRATOR:LEWIS, JESSICAFACILITY TYPE:
735
ADDRESS:43505 ELITE LANETELEPHONE:
(661) 466-7049
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 0DATE:
11/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Jessica Lewis - AdministratorTIME COMPLETED:
12:15 PM
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A Required One (1) year visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator Jessica Lewis. Purpose of visit was stated. This is a North Los Angeles Regional Center (NLARC) vendored facility and level is to be determined. There is no client at this time.

A tour of the physical plant was conducted at 9:45 AM and the following were noted:

The main door is the only entrance being utilized for entry. There is a sign on the door that everyone entering at the facility must wear mask and must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted on the walls. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has three (3) shared client bedrooms and two (2) bathrooms. There are two (2) additional room designated for staff use and an additional bathroom also for staff use. The swimming pool in the backyard is appropriately fenced.

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2023
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: MELONIE & JESSIE JAMES JR. ARF
FACILITY NUMBER: 197610105
VISIT DATE: 11/26/2023
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(continued from LIC 809)

Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the cabinet in the kitchen. Food: The facility is observed to have sufficient emergency food supply for the incoming clients. Temperature of facility wall thermostat is set at 72.0°F and observed to be within the required range. Fire extinguisher: There is a fire extinguisher in the facility located in the main entrance door. Extinguisher was observed to be operable and current. Smoke and carbon monoxide alarms are hardwired and interconnected, tested and observed to be operable.
Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at 110.2°F and within the required range.
Laundry area before the garage entrance. Cleaning solutions and laundry detergents are observed kept in the locked cabinet in the laundry area.
Client records There is no client at this time.
Medication will be kept in a locked kitchen cabinet. There are two (2) complete first aid kits at the medication cabinet.
Staff records There is no client at this time.

There was no immediate health and safety hazard observed during the day of inspection.

Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2023
LIC809 (FAS) - (06/04)
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