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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801530
Report Date: 03/22/2022
Date Signed: 03/22/2022 06:12:38 PM

Document Has Been Signed on 03/22/2022 06:12 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:MJ FAMILY HOMEFACILITY NUMBER:
565801530
ADMINISTRATOR:MARI ONGFACILITY TYPE:
735
ADDRESS:4400 FROST DRIVETELEPHONE:
(805) 488-3179
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
03/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Maria MirandaTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Case Management - Incident inspection at the facility today. Tri-Counties Regional Center Quality Assurance Specialist (QAS) Liz Aced-Arnett was also present. When the LPA and QAS arrived at 10:00 AM, there was no one at the facility. The LPA contacted Licensee Representative Maria Miranda and she arrived at 11:25 AM.

The reason for today's inspection is to follow up on two self reported incidents pertaining to Client #1 (C1), Client #2 (C2), and Staff #1 (S1) on 03/10/2022 and follow up information that was received on 03/14/2022. During today's inspection, the LPA reviewed facility beginning at 11:34 AM and obtained pertinent copies. The clients arrived during the inspection. The LPA and QAS conducted an interview with C2 at 12:13 PM.

Further investigation is needed. Exit interview conducted with Maria Miranda. A copy of the report will be emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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