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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801257
Report Date: 06/29/2024
Date Signed: 06/29/2024 01:53:02 PM

Document Has Been Signed on 06/29/2024 01:53 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:EJ2 FAMILY HOMEFACILITY NUMBER:
565801257
ADMINISTRATOR/
DIRECTOR:		MARIA MIRANDAFACILITY TYPE:
735
ADDRESS:1210 NELSON PLACETELEPHONE:
(805) 271-9449
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
06/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:53 AM
MET WITH:Maria MirandaTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
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At 09:53 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 five (5) clients present. The LPA was greeted by Direct care staff Airica Abundo and informed them of the reason for the visit. Administrator Maria Miranda arrived shortly after.

At 10:31 a.m., the LPA conducted a tour of the physical plant with Direct Care staff Airica Abundo 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 4-G home. The LPA observed two (2) fire extinguishers at the facility, which were fully charged and last serviced 01/18/2024. At 10:36 a.m., all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the dining room.

Kitchen: During the facility tour the kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient supply of perishable and non-perishable food at the facility; Sharp objects and cleaning supplies 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 LPA observed client bedrooms furnished with at least one night-stand, bed and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets.

Bathrooms: The LPA observed the client’s bathroom to be clean, and properly supplied. Clients have sufficient supplies for personal hygiene. At 1:16 p.m., water temperature in the resident’s restroom was measured at 116.0 degrees Fahrenheit. Report will continue on LIC809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2024
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: EJ2 FAMILY HOME
FACILITY NUMBER: 565801257
VISIT DATE: 06/29/2024
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Common Areas: These included the living, dining area and backyard. 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. The facility maintained a comfortable temperature of 73 degrees. The LPA observed appropriate outdoor furniture in the backyard, however there was no covered shaded area for clients. Upon observation care staff stated that due to the weather the umbrella was destroyed and showed the LPA proof that a new umbrella had already been ordered with an expected arrival of July 1st. There are no bodies of water on the premises. There were no obstructions and/or tripping hazards throughout the facility.

The garage: The LPA observed the garage, where the washer and dryer are held, and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. The garage is not locked.
Infection Control: There was a central entry point for symptom screening and temperature checks. Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. The facility's procedures as it pertains to infection control are adequate.

Record Review: At 11:20 a.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the dining room. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 06/27/2024). The LPA reviewed five (5) staff Files and (5) of six (6) client files. All documents reviewed appeared complete and current. P&I money and records were reviewed. Cash resources were separate and intact, and not be commingled with facility funds or petty cash.

Medications: At 12:18 p.m. medications for two clients were reviewed. Medications are centrally stored and locked in a cabinet in the dining room; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Interviews: During the visit the LPA conducted two (2) client, and one (1) staff interview. No immediate concerns voiced at this time

Exit Interview conducted and report was provided to the administrator.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2024
LIC809 (FAS) - (06/04)
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