405801226-6-5-2024-29-AS-MRAN-D5XTH9-20240605144424

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405801226
Report Date: 06/05/2024
Date Signed: 06/05/2024 02:44:42 PM

Document Has Been Signed on 06/05/2024 02:44 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	JAJ RESIDENTIAL CARE FOR ELDERLY		FACILITY NUMBER:	405801226
ADMINISTRATOR:	JOE D. CASTILLO		FACILITY TYPE:	740
ADDRESS:	517 LOS OSOS VALLEY ROAD		TELEPHONE:	(805) 528-7740
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY:	6	CENSUS:	DATE:	06/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Joe Castillo		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rankin arrived at 10:20 am to conduct a 1-year annual visit to the facility above. LPA met with Licensee/Administrator Joe Castillo and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has submitted a current Mitigation Plan, Infection Control Plan, Emergency Disaster Plan and provided plans to the department. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, paper towels, hand soap, and hand washing signs. The facility has EPA approved disinfectants spray and cleaners. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). All trash cans and waste baskets have tight fitting covers. Physical Plant & Environment Safety: The facility is a 5 bedroom and 2 bathrooms currently occupying 4 residents and employs 2 staff, 1 bedroom and 1 bathroom are available for use of live-in staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has a carbon monoxide detector and smoke alarms. The lighting and lamps are sufficient for the use of the facility and for resident’s comfort. The showers have non-skid textured floors and a bath mat. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JAJ RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 405801226
	VISIT DATE: 06/05/2024

NARRATIVE

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The pathways are clear of any obstructions and well lit. Disinfectant, cleaning solutions and poisons are locked and inaccessible to residents in care. The facility has sufficient space inside and outside for activities and visiting. The facility has telephone and internet service for resident use.

Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 06/15/2024. The facility is approved for a capacity of 6 Non-Ambulatory and has a current Hospice wavier granted for 1.

Staffing: The facility employes 2 staff and 1 Administrator. Staff records are kept confidential. Staff files were reviewed for 1st Aid/CPR, Health Screening with TB results, Fingerprint/Back ground clearances, Personnel Record/Applications, Reporting Abuse, and Criminal Record Statement all files are complete.

Personnel Records & Training: Staff files and training records were reviewed on this visit. Both staff had completed required 2024 Annual Training of 20 hours on general requirements, Dementia Care, Restricted Health Conditions, Postural Supports and Hospice Care.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Four files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for any resident in care. Facility does submit incident reports to the department when required.

Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JAJ RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 405801226
	VISIT DATE: 06/05/2024

NARRATIVE

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Resident Rights Information: All required postings were posted in the common area of the facility. The facility has a working telephone for resident use. Internet is provided with confidentiality and privacy for each resident if needed.

Planned Activities: The facility offers and encourages activities to all residents in care. The facility has sufficient space to allow for activities indoors and outdoors.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7 day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately from food supply. Kitchen areas are kept clean and free from litter, rodents, vermin, and insects. Kitchen staff were observed for personal hygiene and food sanitation practices.

Incidental Medical & Dental: The medications records were reviewed for the Centrally Stored Medication and Destruct Records (CSMDR) and Medication Administrator Records (MAR). Records were up to date, legible and given as prescribed. LPA completed a full audit on two residents’ medications, all medications were in original containers, prescription labels were not altered, doctors’ orders were present and dispensing instructions were followed.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 02/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency and a file with resident’s emergency information is present for each resident in care.

Residents with Special Health Needs: All items that could pose a danger such as sharps, and cleaners were locked and inaccessible to residents in care. The facility does not have delayed egress. The facility has 1 hospice residents in care. Hospice care plan was present in resident file.

Exit interview conducted and copy of report printed for Licensee/Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024

LIC809 (FAS) - (06/04)

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