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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610608
Report Date: 09/26/2025
Date Signed: 09/26/2025 03:34:24 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/26/2025 03:34 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:
09/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Malaika SmithTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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On 09/08/2025 at 2:00 pm Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility to conduct an unannounced one (1) year required annual visit. LPA was greeted and granted access by Administrator Jamesha Smith, LPA informed Administrator of the purpose of the visit and an entrance interview was conducted. Administrator would not be able to stay for long and designated Malaika Smith to sign the report.

A tour of the facility was conducted with designee at 2:15 pm. The facility has five (5) bedrooms and three (3) bathrooms. There is a small room near the entrance that is used as an office area but is not considered a bedroom. The facility is Fire Cleared for six (6) ambulatory clients. No tool kit was used as there were no clients.

Kitchen Area: At 2:25 pm LPA conducted a tour of the kitchen and observed that the kitchen area 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 are locked in a closet in the hallway. Cleaning supplies and chemicals were observed to be locked in the storage room.

Living and dining: At 2:35 pm LPA observed 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) clients. There is a fireplace with a metal barrier. No fireplace tools or fixtures were 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 07/24/25. It is located by the dining room and living room area.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/26/2025
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Laundry: At 2:45 pm LPA observed the laundry room located on the second floor to be locked and inaccessible to clients. Cleaning detergents and supplies are locked in the laundry room.

Client Rooms: At 2:50 pm LPA observed that there are five (5) bedrooms designated for client use. Four (4) rooms are designated to be private rooms. Bedroom #3 will be shared. The client bedrooms are equipped with beds, nightstands, chairs, dressers, bedding and linen. All rooms had sufficient lighting.

Bathrooms: At 3:00 pm LPA observed all bathrooms to have the appropriate wash your hands signs posted. Hot water was tested and measured at 112°F. Bathrooms are equipped with paper towels and trash cans with lids, the use of cloth hand towels is not permitted. All clients will have their own towels and are not shared.

Outside Area: At 3:20 pm LPA observed that 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 body of water.

Staff and Client Files: File review was not conducted as there are no clients.

Interviews: No interviews conducted as there are no clients.

Administrative: Bond and Administrator Certificate will be emailed to LPA. The annual fee is current.

No citations issued. Exit interview conducted. A copy of this report was given to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC809 (FAS) - (06/04)
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