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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801530
Report Date: 06/24/2022
Date Signed: 06/24/2022 04:08:22 PM

Document Has Been Signed on 06/24/2022 04:08 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:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Maria MirandaTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required 1 Year inspection at the facility today. The LPA initially met with the caregiver and advised them of the reason for today's inspection. There are currently four caregivers and six clients present. Licensee Representative Maria Miranda was contacted and arrived at the facility at approximately 2:20 PM. The facility is vendored by Tri Counties Regional Center as a level 4-I home.

This annual had a specific emphasis on infection control practices and procedures. The LPA, along with the caregiver and the Licensee Representative, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The kitchen and food storage areas were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored. Items that could pose a danger were secured in a locked cabinet.

COMMON SPACES: In the common areas, furniture, walls, and flooring were clean and in good condition at the time of the inspection. All indoor and outdoor passages were free of obstruction. The fire extinguisher was fully charged and last serviced on 02/08/2022. At 2:29 PM, the carbon monoxide detector and smoke detectors in the common areas and bedrooms were tested and were operational. Medications and records are centrally stored in a locked cabinet in the living room area. Cleaning supplies were observed to be locked in the garage and inaccessible to clients in care. The backyard has outdoor seating for client use.

BEDROOMS: There are four client bedrooms and one staff bedroom. The LPA observed the client bedrooms to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.



Report continued on LIC 809-C.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: MJ FAMILY HOME
FACILITY NUMBER: 565801530
VISIT DATE: 06/24/2022
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RESTROOMS: The facility has two common restroom for client use. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 2:25 PM, the hot water temperature was measured in one common restroom and it measured at 107.6 degree F.

INFECTION CONTROL: During today’s visit, the LPA spoke with the staff regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE). The facility’s cleaning protocol is sufficient. Infection control signs were posted at the entry, throughout the facility, and in the restrooms. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview and reported reviewed with the caregiver. A copy of the report was emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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