421703793-11-7-2024-29-AS-EMIR-DASTCM-20241107133659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 421703793
Report Date: 11/07/2024
Date Signed: 11/07/2024 01:37:11 PM

Document Has Been Signed on 11/07/2024 01:37 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:	JENNY'S BOARD & CARE		FACILITY NUMBER:	421703793
ADMINISTRATOR/ DIRECTOR:	JOHANNA N PEREZ-MEMBREBE		FACILITY TYPE:	735
ADDRESS:	1736 N. RUSSELL AVENUE		TELEPHONE:	(805) 346-8571
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY: 6		CENSUS: 6	DATE:	11/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:13 AM
MET WITH:	Johnanna Perez-Membrebe, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:45 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) Erika Miller arrived at 9:15 a.m. to conduct a 1-year required annual visit. LPA met with Johanna N. Membrebe, Administrator. LPA was authorized to enter and inspect facility. A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has at least a 30-day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE). Physical Plant & Environment Safety: LPA toured resident rooms and observed that rooms were sufficiently tidy. The lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational. The showers have non-skid mats. The pathways are clear of any obstructions. Disinfectant and cleaning solutions are inaccessible to residents in care and locked in garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. The fire extinguisher was last charged and inspected on 10/15/24. The facility has smoke and carbon monoxide detectors that were tested and inspected. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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: JENNY'S BOARD & CARE	FACILITY NUMBER: 421703793
	VISIT DATE: 11/07/2024

NARRATIVE

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Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility is approved for a capacity of 6 ambulatory and has current census of 6 ambulatory residents.

Staffing: The facility currently employs 5 full time staff and 1 administrator. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance/Associations/exemptions. Administrator Certificate expires on 11/15/24.

Personnel Records & Training: The facility keeps confidential files for each staff member.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, Physicians report, Pre-appraisals, Appraisals Needs and Services Plan, Emergency and ID forms. All forms were legible.

Food Service: The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered and stored, appropriately. Cleaning solutions and equipment are stored separately from food supplies.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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: JENNY'S BOARD & CARE	FACILITY NUMBER: 421703793
	VISIT DATE: 11/07/2024

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Incidental Medical Services: Facility provides transportation or assists in providing transportation to medical and dental appointments when needed. The facility uses the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired, and all medications were kept in their original containers.

Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a quarterly disaster drill on 10/29/24. 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.

Residents with Special Health Needs: The facility has 1 self-latching gate on side of the home. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC809 (FAS) - (06/04)

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