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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801530
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:34:19 PM

Document Has Been Signed on 04/14/2023 04:34 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:
04/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Joemar OngTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) KaSandra Lopez and Kevin Gaines 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 Joemar Ong was contacted and arrived at the facility at approximately 9:03 AM. The facility is vendored by Tri Counties Regional Center as a level 4-I home.

The LPA, along with 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 box. During the inspection, the LPA observed the cabinet under the sink with cleaning supplies to be unsecured.

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 01/29/2023. At 9:14 AM, 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: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2023
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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Document Has Been Signed on 04/14/2023 04:34 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 04/14/2023 at 11:34 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MJ FAMILY HOME
FACILITY NUMBER: 565801530

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above as cleaning supplies were observed in an unlocked cabinet under the kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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The cabinet was secured during the inspection. The Licensee agrees to conduct an in-service training for all staff regarding regulation 80087(g) and submit to CCL on 04/21/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2023 04:34 PM - It Cannot Be Edited


Created By: Kasandra Lopez On 04/14/2023 at 11:34 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MJ FAMILY HOME
FACILITY NUMBER: 565801530

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one staff (Staff #1) out of five staff had an expired first aid card which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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The Licensee shall submit proof Staff #1 (S1) has current first aid training by 04/21/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2023


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: 04/14/2023
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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 9:17 AM, the hot water temperature was measured in one common restroom and it measured at 117 degree F.

MEDICATIONS: Medications are locked and centrally stored in the living room. At 9:49 AM medications for two clients were reviewed. All medications are labeled and maintained in compliance with label instructions, and state and federal law. All medications reviewed were recorded on the centrally stored medication and destruction record. The LPA inspected the first aid kit, which was complete.

RECORDS: At 9:58 AM record review for five clients and five staff was conducted. Client files reviewed were found to be complete. P&I money and records were reviewed. Cash resources were separate and intact, and not be commingled with facility funds or petty cash. Staff files reviewed were complete except for one staff out of five staff having an expired first aid card.

Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 1 & 6, the following deficiencies was observed and cited during the visit. See 809-D. Exit Interview conducted and the report was reviewed with the Joemar Ong. Appeal Rights and a copy of this report has been issued.

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

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC809 (FAS) - (06/04)
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