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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801226
Report Date: 06/26/2023
Date Signed: 06/27/2023 08:43:37 AM

Document Has Been Signed on 06/27/2023 08:43 AM - 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: 5DATE:
06/26/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Joe Castillo, AdministratorTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon arrived at 2:15 pm to conducted a Case Management Annual Continuation visit to the facility above. LPA met with Licensee/Administrator Joe Castillo and explained the purpose of the visit.

LPA returned to the facility to complete the annual visit. LPA reviewed staff files, Staff Training Records and conducted interviews on staff and residents in care.


Staffing: The facility employes 4 staff and 1 Administrator. Staff records are kept confidential. Staff files were reviewed for 1st Aid/CPR, Health Screening with TB results, Finger print/Back ground clearances, Personnel Record/Applications, Reporting Abuse, Criminal Record Statement. At 3:30 PM LPA noted that 2 out of 5 staff were missing original TB results and 1/5 staff was missing original Health Screening. Administrator has misplaced original documents and has made appointments for 2 staff to get a new TB result, 1 staff to get a new health screening and will provide all copies to CCL.

Personnel Records & Training: Staff files and training records were reviewed on this visit. All 5/5 staff had completed required 2023 Annual Training of 20 hours on general requirements, Dementia Care, Restricted Health Conditions, Postural Supports and Hospice Care.

Licensee/Administrator provided LPA will copies of all missing residents forms from last visit.

Exit interview completed, Deficiency cited, copy of report and appeal rights printed/emailed to Licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 06/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/26/2023
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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Document Has Been Signed on 06/27/2023 08:43 AM - It Cannot Be Edited


Created By: Rachael De Leon On 06/26/2023 at 03:28 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JAJ RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 405801226

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2/5 staff were missing TB resulta and 1out of 5 staff were missing health screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2023
Plan of Correction
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Licnesee/Administrator agreed to provide copies of missing TB results for 2/5 staff and health screening for 1/5 staff to CCL by 07/03/2023.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 06/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/26/2023


LIC809 (FAS) - (06/04)
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