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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801256
Report Date: 07/03/2024
Date Signed: 07/03/2024 12:52:30 PM

Document Has Been Signed on 07/03/2024 12:52 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:EJ'S FAMILY HOMEFACILITY NUMBER:
565801256
ADMINISTRATOR/
DIRECTOR:		WILHEMINA ONGFACILITY TYPE:
735
ADDRESS:4901 HAMILTON AVENUETELEPHONE:
(805) 488-3411
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 5DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Maria Miranda-Co administratorTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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At 10:10 a.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. When the LPA arrived, there were three (3) staff and three (3) clients present. The LPA was greeted by caregiver Celia Purvis and informed them of the reason for the visit. Co-Administrator Maria Miranda arrived shortly.

At 10:20 a.m. the LPA conducted a tour of the physical plant with Administrator Maria to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of three (3) client bedrooms, one (1) staff room, and two (2) bathrooms. The home is vendored by Tri-Counties Regional Center as a level three home. The LPA observed fire extinguishers throughout the facility, which were fully charged and last serviced 06/18/2024. At 10:28 a.m., all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings throughout the home.

Kitchen: During the facility tour at 10:26 a.m., the LPA observed the appliances and fixtures functional during the time of visit. The LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects are stored in locked drawers and cabinets. Food is prepared based on the menu and modified as needed for individual clients. Snacks and beverages are always available for clients.
Bedrooms: The client bedrooms were properly furnished with at least one chair, night-stand and sufficient lighting for each client. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases and blankets.
Bathrooms: The LPA observed all bathrooms to be clean, properly supplied and had functional fixtures. Clients have sufficient amounts of supplies for personal hygiene. At 10:33 a.m., the water temperature in one of the restroom was measured at 113. degrees Fahrenheit.
Report will continue on LIC809-C
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2024
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: EJ'S FAMILY HOME
FACILITY NUMBER: 565801256
VISIT DATE: 07/03/2024
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Common Areas: These included the living, dining area, and office. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen and blocked by furniture. The facility maintained a comfortable temperature of 71 degrees. There were no obstructions and/or tripping hazards throughout the facility.
The garage: The LPA observed the garage where additional perishable and nonperishable food items and emergency water was stored. The garage is used for storage and inaccessible to the clients.
Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. At 10:39 a.m. the LPA observed two (2) Laundry detergent buckets filled with motor oil and one (1) fabric softener container also filled with motor oil in between one of the sheds and brick wall in the backyard, accessible to the clients in care. At 10:41 a.m. the LPA observed one (1) laundry detergent bucket filled with motor oil, one (1) 5 US QT container of Kirkland Full synthetic SAE 5W-20 motor oil, and one (1) additional motor oil container on the side of the home in between the side gate and a shed accessible to clients in care. Upon observation staff removed all containers, and stored them inaccessible to clients in care.
Interviews: Between 10:10 a.m., and 10:20 a.m., the LPA conducted two (2) client interviews. At 12:30 p.m. the LPA conducted two (2) staff interviews. No immediate concerns voiced at this time.

Record Review: At 11:05 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the office area. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 06/15/2024). The LPA reviewed five (5) of five (5) Client Files and (5) of five (5) staff files. All documents reviewed appeared complete and current. At :11:34 a.m. P&I money and records were reviewed for four clients. Cash resources were separate and intact, and not be commingled with facility funds or petty cash

Medications: A medication audit for two (2) of five (5) clients was initiated at 12:05 p.m., and the following was observed. Medications are centrally stored and locked in a cabinet in the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors were observed.



Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights were provided to the administrator.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2024 12:52 PM - It Cannot Be Edited


Created By: Esther Cortez On 07/03/2024 at 12:35 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: EJ'S FAMILY HOME
FACILITY NUMBER: 565801256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as the LPA observed six (6) containers filled with motor oil in the back yard and side of the yard, accessible to the clients in care which poses an immediate health and safety risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
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Plan of correction has been met. All items were removed during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024


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