565801256-7-28-2022-29-AS-KLOZ-CF7249-20220607170335

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801256
Report Date: 06/07/2022
Date Signed: 07/28/2022 11:08:52 AM

Document Has Been Signed on 07/28/2022 11:08 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:	EJ'S FAMILY HOME		FACILITY NUMBER:	565801256
ADMINISTRATOR:	WILHEMINA ONG		FACILITY TYPE:	735
ADDRESS:	4901 HAMILTON AVENUE		TELEPHONE:	(805) 488-3411
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 5	DATE:	06/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:18 PM
MET WITH:	Maria Miranda		TIME COMPLETED:	03:40 PM

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year inspection at the facility today. This Required - 1 Year inspection has a specific emphasis on infection control practices and procedures. The LPA initially met with Co-Administrator Edwin Miranda and caregiver Alice Diche and explained the reason for the inspection. Licensee Representative Maria Miranda was notified by telephone of the inspection and arrived at the facility at approximately 2:30 PM.

At 2:20 PM, the LPA, along with the caregiver toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The home is vendored by Tri-Counties Regional Center as a level three home. There is currently two caregivers and four clients present in the facility.

Kitchen The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and garage. Knives and items that could pose a danger were secured in locked cabinets. Medications are stored in a locked cabinet in the kitchen. The fire extinguisher in the kitchen area was observed to be fully charged and serviced on 02/08/2022.

Common Areas: The living room area is furnished appropriately. Infection control signs are posted through out the facility. At 2:34 PM the carbon monoxide detector and smoke alarms were tested and found to be operational at this time. The facility has two commons restrooms for resident use. Restrooms were observed to be clean and sanitary with hand soap and paper towels. The hot water temperature in the common hallway restroom measured at 119.5 degrees F. Facility records are stored in a locked cabinet in the office area. The backyard has covered seating for client use.

Bedrooms: The LPA observed the three client bedrooms. The bedrooms were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: EJ'S FAMILY HOME	FACILITY NUMBER: 565801256
	VISIT DATE: 06/07/2022

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Infection Control: During today’s visit, the LPA spoke with Ms. Miranda regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. Infection control signs are posted in the restrooms and through out the facility. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room. The facility’s policies and procedures as it pertains to infection control are adequate.

Licensee Representative Maria Miranda stated she will submit documents to update the Administrator of record as Edwin Miranda.

No deficiencies were cited. Exit interview and report reviewed with the Ms. Miranda. A copy of the report was emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022

LIC809 (FAS) - (06/04)

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