565801897-1-13-2023-29-AS-KLOZ-CN2UJD-20230113143721

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801897
Report Date: 01/13/2023
Date Signed: 01/13/2023 02:37:27 PM

Document Has Been Signed on 01/13/2023 02:37 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:	JEMIE FAMILY HOME		FACILITY NUMBER:	565801897
ADMINISTRATOR:	ERIK MIRANDA		FACILITY TYPE:	735
ADDRESS:	4221 HIGHLAND AVENUE		TELEPHONE:	(805) 246-5569
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY: 6		CENSUS: 6	DATE:	01/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Joemar Ong		TIME COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced Required - 1 Year inspection at the facility today. This home is vendored by Tri-Counties Regional Center as a level 4-I home for six residents. Licensee Representative Joemar Ong arrived shortly after the inspection began.

This annual had a specific emphasis on infection control practices and procedures. The LPA 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 in the garage were observed. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food stored in the kitchen and garage. Cleaning supplies are stored in locked cabinets in the garage. Knives and items that could pose a danger are in locked cabinets and drawers.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and dining room furniture was observed to be in good condition. The fire extinguisher was fully charged and last serviced 02/08/2022. The carbon monoxide detector and smoke detectors in the home and bedrooms were tested and were operational. Medications and facility records are centrally stored and in a locked cabinet in the living room. The backyard has covered seating for resident use.

BEDROOMS: There are four resident bedrooms. The LPA observed the resident bedrooms, which were 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: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

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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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: JEMIE FAMILY HOME	FACILITY NUMBER: 565801897
	VISIT DATE: 01/13/2023

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RESTROOMS: The facility has one common restroom and one on-suite restroom for resident use. Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee Representative 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 needed. The facility’s policies and procedures as it pertains to infection control are adequate.

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

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

LIC809 (FAS) - (06/04)

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