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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801226
Report Date: 05/05/2022
Date Signed: 05/05/2022 03:17:12 PM


Document Has Been Signed on 05/05/2022 03:17 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. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:JAJ RESIDENTIAL CARE FOR ELDERLYFACILITY NUMBER:
405801226
ADMINISTRATOR:JOE D. CASTILLOFACILITY TYPE:
740
ADDRESS:517 LOS OSOS VALLEY ROADTELEPHONE:
(805) 528-7740
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:6CENSUS: 3DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joe Castillo, AdministratorTIME COMPLETED:
03:25 PM
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Licensing Program Analyst's (LPA) De Leon conducted an on site 1 year infection control annual visit to the facility above on 05/05/2022 at 2:00 PM. LPA met with Joe Castillo Administrator and explained the purpose of the visit.

Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department and it has been approved. The facility has an entry point at the front door where everyone entering completes sign-in, symptom, and temperature screening. All documentation is kept on a clipboard and filed in binder daily. The entry station has hand sanitizer along with a thermometer. The facility has a large living room area that is used for activities and exercise, all areas are spaced to accommodate as much space as possible for social distancing. All equipment and PPE supplies are kept in a cabinet accessible to all staff. Medications are kept in a locked cabinet in the kitchen area. The kitchen area has a dining area to accommodate distancing between residents when eating meals . The staff screen residents for symptoms and temperature 1 x's a day. Increased monitoring is conducted if any change of condition is noted or any residents is showing any signs, symptoms or has a temperature, change of conditions are documented and kept on file. Signs are posted on the hallway walls through out the facility regarding Covid-19. All required postings are hung in common areas of the facility. Staff makes sure residents have a mask when leaving the facility on outings into the community. All staff wear face coverings in the facility and when on outings with residents.
Facility has several areas for visiting inside and outside. The facility also offers virtual and telephone communications to all residents in care. The Facility has hand sanitizer located thorough out the house. Staff, residents and visitors are informed of the facilities infection control policies. New residents and staff will be tested and negative results received before working or residing in the facility. Continued 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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 3


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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JAJ RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 405801226
VISIT DATE: 05/05/2022
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The facility has procedures and plans for screening, isolation, testing, when to call 911 and notifying all responsible parties and agencies when needed. Emergency Disaster plan is posted and all agencies with telephone numbers are listed. Administrator is in charge of infection control and provides training and education to staff, residents and visitors. Administrator is in charge of staffing and works on any issues or additional coverage. If any suspected or confirmed cases of Covid-19 are found in the facility staff will be assigned to only work with those individuals. Staff will use full PPE with N95 masks and face shields when dealing with any pending or confirmed cases of Covid-19. Facility is able to dedicate a single room for resident so isolation can be arranged when and if needed. The facility has 3 resident bedrooms, 1 resident restroom and 1 live-in staff room. Restrooms are disinfected after use. Signs will be posted on any room with quarantine or isolated individuals. PPE supplies will be located right outside those rooms when required. Facility has a 30 day supply of PPE on hand. Trash bins had tight fitting lids. Facility has plans for delivering medications and meals to any quarantined/isolation room. The facility has proper cleaning and disinfectant sprays. The facility has not been fitted tested for N95 masks and LPA explained in an outbreak the facility would need to be wearing N95 and CAL OSHA requires the fit testing of those masks. Facility Administrator has a plan in place for when and whom to notify in an outbreak or other emergencies. Administrator will keep a line list of all vaccinated and tested staff/residents in care with dates/results. Facility has conducted training on infection prevention, symptoms, transmission and PPE use. Facility has non-punitive sick leave polices for staff. Sick staff are requested to stay home and not report to work if ill. Activities have been modified to individuals or small groups with social distancing. Furniture has been moved around to accommodate social distancing between staff and residents. Residents medication is delivered in 30 day supplies to the facility. The facility ensures proper cleaning is done on frequently touched surfaces and between any individuals sharing of space or items. Sinks were well stocked with soap and paper towels. Staff and resident records are kept locked in cabinets. Facility does realize guidance changes and the most up to date guidance from CCL-PINS, CDC, CDPH, and local health departments should be followed to remain in compliance. The most stringent orders should be followed by those agencies.
Continued 809-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JAJ RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 405801226
VISIT DATE: 05/05/2022
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 The facility had plenty of perishable food for 2 plus days and non-perishables for 7 plus days. The facility maintains an emergency food and water supply. Administrator Certificate is valid. Smoke detectors are hard wired through-out the facility. Fire Extinguishers are charged and inspected annually.
No deficiencies observed during the visit and all infection control protocols are implemented and followed.

Exit interview completed and copy of report given to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
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