565801530-6-28-2024-29-AS-ECOZ-D6NV4P-20240628160641

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801530
Report Date: 06/28/2024
Date Signed: 06/28/2024 04:07:06 PM

Document Has Been Signed on 06/28/2024 04:07 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:	MJ FAMILY HOME		FACILITY NUMBER:	565801530
ADMINISTRATOR/ DIRECTOR:	MARI ONG		FACILITY TYPE:	735
ADDRESS:	4400 FROST DRIVE		TELEPHONE:	(805) 488-3179
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 6	DATE:	06/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:50 PM
MET WITH:	Maria Miranda		TIME VISIT/ INSPECTION COMPLETED:	04:15 PM

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Licensing Program Analyst (LPA) Esther Cortez 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 were two caregivers and four clients present. Licensee Representative Maria Miranda was contacted and arrived shortly thereafter. Two (2) additional staff arrived during the visit. 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.

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 01/18/2024. At 2:00 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 LPA observed appropriate outdoor furniture with a shaded area for residents in the backyard. There are no bodies of water on the premises.

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: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024

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: MJ FAMILY HOME	FACILITY NUMBER: 565801530
	VISIT DATE: 06/28/2024

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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 2:16 PM, the hot water temperature was measured in one common restroom and it measured at 109.6 degree F.

INTERVIEWS: The LPA conducted two (2) client interviews. No immediate concerns were voiced at this time.

RECORDS: At 2:24 PM 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 current and complete.

MEDICATIONS: Medications are locked and centrally stored in the living room. At 3:16 PM 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.

Exit Interview conducted and the report was reviewed with Maria Miranda and a copy of this report has been issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2024

LIC809 (FAS) - (06/04)

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