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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610608
Report Date: 07/24/2024
Date Signed: 07/24/2024 01:36:20 PM

Document Has Been Signed on 07/24/2024 01:36 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:J.D.S. ADULT CARE FACILITYFACILITY NUMBER:
197610608
ADMINISTRATOR/
DIRECTOR:		SMITH, JAMESHA D.FACILITY TYPE:
735
ADDRESS:45227 STADIUM CT.TELEPHONE:
(661) 494-9368
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 6CENSUS: 0DATE:
07/24/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Jamesha SmithTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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On 07/24/2024 at 10:00 am, Licensing Program Analyst (LPA) Lorena Casillas conducted an announced Pre-Licensing Inspection with the Administrator Jamesha Smith. An application to operate an Adult Residential Facility (ARF) was received by Community Care Licensing (CCL) on 03/28/2024. A fire clearance was approved on 05/24/2024, for six (6) ambulatory residents. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

The Component III presentation was conducted from 10:05 am until 12:00 pm with Administrator.

A tour of the physical plant was initiated at approximately 12:00 pm and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There was an adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives ware locked in a closet in the hallway.

BEDROOMS: There are five (5) bedrooms designated for resident use. Four (4) rooms are designated to be private rooms. One (1) bedroom will be shared. Bedroom #1, #2, #4 and #5 will be private and bedroom #3 will be shared. The applicant furnished the resident bedrooms with beds, nightstand, chairs, dressers, bedding and linen. All rooms had sufficient lighting.

BATHROOMS: The facility has three (3) bathrooms. All bathrooms were observed to have the proper fixtures, and non-skid mats. The hot water delivered in the bathrooms measured within regulation between 105 and 120 degrees F.

Continued on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: J.D.S. ADULT CARE FACILITY
FACILITY NUMBER: 197610608
VISIT DATE: 07/24/2024
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COMMON AREAS: These included the living room and dining room areas, which were equipped with living room furniture, a television, tables, and chairs. The dining room table is large enough to accommodate six (6) residents. There is a fireplace with a metal barrier. No fireplace tools or fixtures present. The smoke alarms are hard wired and inter-connected. The carbon monoxide detector is functional and installed in the entrance and upstairs. The facility has one fire extinguisher that was purchased on 4/12/24. It is located by the dining room and living room area.

LAUNDRY ROOM: The laundry room is located on the second floor and is locked. Cleaning detergents and supplies are locked in the laundry room.

MEDICATIONS: Medications will be stored in a locked cabinet in the kitchen.

STAFF/RESIDENT RECORDS: Staff and resident records will be stored in a locked cabinet stored in the locked staff room. The applicant was advised to ensure that resident and staff records will be accessible to the licensing agency upon request or during inspection. Facility will have awake staff.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. The backyard has outside furniture and an umbrella for shade. The facility backyard has sufficient yard space to accommodate outdoor activities. There is no swimming pool or bodies of water.

Exit Interview was conducted, and a copy of this report was given to applicant.

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

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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