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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801897
Report Date: 02/07/2024
Date Signed: 02/07/2024 04:47:28 PM

Document Has Been Signed on 02/07/2024 04:47 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:JEMIE FAMILY HOMEFACILITY NUMBER:
565801897
ADMINISTRATOR:ERIK MIRANDAFACILITY TYPE:
735
ADDRESS:4221 HIGHLAND AVENUETELEPHONE:
(805) 246-5569
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
02/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Jose OngTIME COMPLETED:
04:50 PM
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At 01:45 p.m. Licensing Program Analysts (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. When the LPA arrived, there were four (4) staff and four (4) clients present. Licensee Representative Jose Ong arrived shortly after the inspection began.

At 01:55 p.m., the LPA conducted a tour of the physical plant with Licensee Representative Jose Ong to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of four (4) client bedrooms, and two (2) bathrooms. The home is vendored by Tri-Counties Regional Center as a level 4-I home. The LPA observed two (2) fire extinguishers at the facility, which were fully charged and last serviced 01/18/2024. At 02:04 p.m., all smoke alarms and carbon monoxide detectors were tested and functioned properly. LPA observed all required postings in the entrance.

KITCHEN/GARAGE: 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. Food is prepared based on the menu and modified as needed for individual residents. Snacks and beverages are always available for residents. The LPA observed the garage, where the washer and dryer are held, and the emergency food and water is stored. The garage is not locked.

COMMON SPACES/OUTDOORS: These included the living, dining area and backyard. 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. There is a fireplace in the living room, which is covered with a screen and a couch. The backyard has covered seating for resident use. There are no bodies of water on the premises. Report will continue on LIC809-C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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: JEMIE FAMILY HOME
FACILITY NUMBER: 565801897
VISIT DATE: 02/07/2024
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BEDROOMS: There are four resident bedrooms. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Two (2) of four (4) client rooms were observed to not have chairs for residents. The administrator stated the resident for one of the rooms was using their chair in the garage. Chairs were provided for the residents during todays visit.

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.

RECORD REVIEW: At 2:30 p.m., a review of facility files was initiated. Facility records are stored in a locked cabinet in the living room and in a locked cabinet in the kitchen. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 01/13/2024). The LPA obtained Client Roster, Staff Roster, and facility Sketch. The LPA reviewed five (5) of six (6) client Files. All documents reviewed appeared complete and current. The LPA reviewed five (5) of twelve (12) staff files. The following was observed: 2/5 staff files did not have current 1st aid/CPR training, and 1/5 staff files did not have a health screening LIC503 filled out, however did have negative TB test on file.

Interviews: During the visit the LPA conducted three (3) client interviews. No immediate concerns were voiced at this time.



Due to time constraints the LPA will return at a later date to complete the annual.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/07/2024 04:47 PM - It Cannot Be Edited


Created By: Esther Cortez On 02/07/2024 at 04:36 PM
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: JEMIE FAMILY HOME
FACILITY NUMBER: 565801897

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

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 in two (2) out of five (5) staff had expired 1st aid/CPR certificates which poses a potential health and safety risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
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The Administrator agrees to submit proof that both staff have received first aid training by 02/21/2024.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
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