<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801257
Report Date: 06/29/2022
Date Signed: 06/29/2022 04:36:47 PM

Document Has Been Signed on 06/29/2022 04:36 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:EJ2 FAMILY HOMEFACILITY NUMBER:
565801257
ADMINISTRATOR:MARIA MIRANDAFACILITY TYPE:
735
ADDRESS:1210 NELSON PLACETELEPHONE:
(805) 271-9449
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 5DATE:
06/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jose OngTIME COMPLETED:
02:20 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) KaSandra Lopez conducted an unannounced Case Management - Incident inspection regarding a Special Incident Report (SIR) received on 06/27/2022. The LPA met with Assistant Administrator Jose Ong and informed him the reason for the visit.

The SIR received stated on 06/27/2022, Client #1 (C1) called local law enforcement due to Client #2 (C2) making C1 feel uncomfortable. When law enforcement arrived at the facility, they interviewed both C1 and C2. According to the SIR, no report was filed by the police.

During today's inspection, the LPA conducted interviews with C1 and C2 regarding this incident. The LPA also interviewed C1 and C2 about a prior incident reported in December 2021. Interviews with Jose Ong revealed since the December 2021 incident, a female staff is awake in the hallway at night at all times. No deficiencies were observed during the visit. Exit interview conducted with Jose Ong. A copy of the report will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1