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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801897
Report Date: 02/21/2024
Date Signed: 04/19/2024 04:42:46 PM

Document Has Been Signed on 04/19/2024 04:42 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:
02/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joemar OngTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident inspection regarding self reported Unusual Incident/Injury Reports (LIC 624), two (2) received on 02/13/24 and one (1) on 2/14/24, regarding Client 1 (C1), Client 2 (C2), and Client 3 (C3). LPA was joined by Tri-Counties Regional Center(TCRC) Quality Assurance Specialists (QAS) Katy Robison and Patrick Brown. The LPA met with Co-Administrator Joemar Ong and informed him the reason for the visit.

The first self reported Unusual Incident/Injury Reports (LIC 624) received on 2/13/24 pertains to an incident that occurred on 02/11/2024 regarding Client #1 (C1) and Staff#1 (S1). The second self reported Unusual Incident/Injury Reports (LIC 624) received on 2/13/24 pertains to an incident that occurred on 2/12/24 regarding Client #2 (C2). The self reported Unusual Incident/Injury Reports (LIC 624) received on 2/14/24 pertains to an incident regarding C3 and S2 that was video recorded by S1.

During todays visit the LPA and QAS interviewed the Co-Administrator and three (3) staff at 9:15 a.m., 9:56 a.m., 10:52 a.m., and 11:52 a.m. and Interviewed C3 and C1 at 12:37 p.m. and 1:16 p.m. The video recording regarding C3 and S2 was reviewed with the Co-Administrator, the date the video was recorded is currently unknown. S1 and S2 are currently on Administrative leave, however S1 will be returning to the facility today.

Further investigation is needed. No immediate health and safety concerns were observed during the visit and no deficiencies cited at this time. LPA will return at a later date.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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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