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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 01:51:04 PM

Document Has Been Signed on 06/29/2024 01:51 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:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:53 AM
MET WITH:Maria Miranda TIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident inspection at the facility today due to a Special Incident Report (SIR). The LPA was greeted by direct care staff Airica Abundo and the reason for the visit was explained. Administrator Maria Miranda arrived shotly thereafter.

When the LPA arrived at 9:53 AM there were three (3) staff and five (5) clients present. The Administrator Maria Miranda was contacted and arrived at the home during the visit. The home is vendored by TCRC as a level 4-G home.



The purpose of today's inspection is to follow up on a self reported alleged incident that occurred on June 16, 2024 regarding Client #1 (C1) and Client #2 (C2). It was reported that C1 alleged C2 got on top of C1, C1 told C2 to stop and C2 stopped. Both clients were clothed. During today's visit LPA Cortez interviewed the Administrator and C1. Interviews revealed that C1 has been provided support, has no concerns and feels safe at the home. Police report was made by the Administrator and C2 is currently not at the home. Administrator Maria also revealed that staff are frequently checking on the clients to ensure the safety of the clients.

No immediate health and safety concerns were observed during today's inspection. The report was issued to Administrator Maria Miranda.
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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