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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610105
Report Date: 08/19/2024
Date Signed: 08/19/2024 12:12:53 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/19/2024 12:12 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MELONIE & JESSIE JAMES JR. ARFFACILITY NUMBER:
197610105
ADMINISTRATOR/
DIRECTOR:		LEWIS, JESSICAFACILITY TYPE:
735
ADDRESS:43505 ELITE LANETELEPHONE:
(661) 466-7049
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 0DATE:
08/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jessica LewisTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility for an unannounced one (1) year Required visit. LPA arrived at 9:45 am and was greeted by Licensee/Administrator Jessica Lewis, LPA explained the reason for the visit.

Infection control: LPA reviewed the facility mitigation plan (approved on 05/04/22) to make sure licensee was following current infection control recommendations. Administrator took LPA's temperature upon entry.

A tour of the physical plant was conducted with Administrator at 10:00 am. The facility has five (5) bedrooms and three (3) bathrooms currently not occupying clients. The facility is Fire Cleared for six (6) ambulatory clients.

Kitchen: LPA conducted a tour of the kitchen at 10:25 am and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects to be locked and inaccessible to clients. The medication cabinet and first aid kit were observed to be locked.

Common areas: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 80°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 11:20 am. There is one (1) fire extinguisher located in the entrance. The Fire extinguisher was observed to be full and last purchased on 11/26/2023.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MELONIE & JESSIE JAMES JR. ARF
FACILITY NUMBER: 197610105
VISIT DATE: 08/19/2024
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Resident Rooms: LPA observed rooms to have the appropriate bedding. There are nightstands, chairs, and sufficient lighting for each client. Extra linens are located in all the rooms and additional linens and personal care supplies are located in hallway cabinets.

Bathrooms: At 10:45 am LPA observed all bathrooms to have non-skid mats, grab bars, and the appropriated wash your hands signs posted. Hot water was tested at 10:45 am and measured within regulation at 117.9 degrees F.

Physical environment: LPA toured the outside area of the facility at 10:55 am. LPA observed a covered shaded area for clients. There is a pool located in the backyard and is surrounded by a locked gate. The gate is also equipped with an alarm for when the gate is opened, it was tested and operational.

Laundry: LPA observed chemicals/hazardous items in a locked cabinet in the laundry room.

Garage: LPA observed the garage to be attached to the facility and currently being used for emergency food storage, and additional general storage.

Administrative: Annual fee is current.

Staff and Client Interviews: No clients currently in the home, no interviews conducted.

No citations issued. An exit interview was conducted, and a copy of this report was given to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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