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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600173
Report Date: 08/14/2025
Date Signed: 08/14/2025 03:56:52 PM

Document Has Been Signed on 08/14/2025 03:56 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:J-J ADULT CARE HOMEFACILITY NUMBER:
198600173
ADMINISTRATOR/
DIRECTOR:		JOSE & JEAN TIMBOLFACILITY TYPE:
735
ADDRESS:1233 BOYNTON STREETTELEPHONE:
(818) 243-0628
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY: 6CENSUS: 5DATE:
08/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Catherine Abalos, AdminstratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility 10:20 am. LPA was greeted by staff and disclosed the purpose of the visit. The administrator was called and arrived later.
LPA conducted a tour of the physical plant at approximately 11:05 am to ensure there are no health and safety hazards, and the facility is following Title 22 Regulations. Common areas—including the combined living and dining room, as well as the kitchen were evaluated for their ability to safely meet residents' needs. These spaces were inspected for cleanliness, and furniture was assessed for functionality and condition. All common areas were found to be clean, sanitary, and furnished with seating sufficient to accommodate residents comfortably.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the five (5) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with frozen foods. Food pantry in living cabinet stocked with canned goods and boxed foods. Resident medications and first aid kit are stored in lower kitchen cabinet and container on top of the cabinet near the kitchen table. Sharps are stored in kitchen drawer. Medications and sharps observed to be locked and inaccessible to residents in care. Toxins are stored and locked under kitchen sink and observed to be locked and inaccessible to residents. The laundry room is located behind the kitchen. The appliances observed to be functional. The locked cabinets above the washer and dryer contain toxins observed to be locked and inaccessible to residents.
NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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 5
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: J-J ADULT CARE HOME
FACILITY NUMBER: 198600173
VISIT DATE: 08/14/2025
NARRATIVE
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(cont from 809)

There are three (3) fire extinguishers in the facility attached to the wall: one (1) in the kitchen, one (1) in the hallway near den and one (1) outside attached patio deck siding -all observed to be charged.

The facility has a total of four (4) bedrooms with two (2) shared and one (1) staff room and three (3) bathrooms for residents’ use. The residents’ bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets.

Each bathroom has the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the three (3) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 106.2-119.0 degrees Fahrenheit.

The backyard has the following: Covered patio with two (2) tables and chairs. Patio furniture was observed to be in good repair with adequate seating for residents. detached garage: Additional refrigerator for food, incontinent supplies and storage. The carbon monoxide detector/smoke detectors were available and/or tested and operable at the time of visit.
At approximately 12:45 pm, LPA reviewed four (4) random staff files and five (5) resident files. Staff files had current First aid and CPR certificates and fingerprinting clearances. Resident files included physicians’ reports, quarterly reports and admission agreements.

809D notes the following deficiencies: Heat exposed drinking water stored unshaded in backyard-disposed at time of visit, loose/missing/ broken bricks and holes on grounds, unserviceable sheds/bins in backyard/unserviceable van/clutter on sides of detached garage/unsecured sharp tools/equipment and flammable cans/paint.

Exit Interview Conducted /Copy of report given

NAME OF LICENSING PROGRAM MANAGER: Naira Margaryan
NAME OF LICENSING PROGRAM ANALYST: Tihesha Smith
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/14/2025 03:56 PM - It Cannot Be Edited


Created By: Tihesha Smith On 08/14/2025 at 03:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: J-J ADULT CARE HOME
FACILITY NUMBER: 198600173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) ], the licensee did not comply with the section cited above in due to loose, missing, broken bricks/clutter which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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WIll have items removed/cleaned and will provided pictures
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above due to flammable cans/paint, sharp equipment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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WIll have items removed and will provided pictures
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Tihesha Smith
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2025 03:56 PM - It Cannot Be Edited


Created By: Tihesha Smith On 08/14/2025 at 03:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: J-J ADULT CARE HOME
FACILITY NUMBER: 198600173

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above due to unlocked, unserviceabe shed/bins which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2025
Plan of Correction
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Sheds/bin will be removed asap and will provide pictures.
Type A
Section Cited
CCR
80076(a)(14)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (14) All foods or beverages capable of supporting rapid and progressive growth of microorganisms which can cause food infections or food intoxications shall be stored in covered containers at 45 degrees F (7.2 degrees C) or less.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) , the licensee did not comply with the section cited above due to plastic drinking water drums stored unshaded in direct sunlight which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2025
Plan of Correction
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Drinking water poured out at time of visit/ LPA Smith observed empty drums. Cleared
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Naira Margaryan
NAME OF LICENSING PROGRAM MANAGER:
Tihesha Smith
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2025


LIC809 (FAS) - (06/04)
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