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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801897
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:45:32 PM

Document Has Been Signed on 05/08/2024 04:45 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/
DIRECTOR:		ERIK MIRANDAFACILITY TYPE:
735
ADDRESS:4221 HIGHLAND AVENUETELEPHONE:
(805) 246-5569
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 6DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Erik MirandaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management - Incident inspection at the facility today due to a Special Incident Report (SIR). The LPA was greeted by administrator Erik Miranda and the reason for the visit was explained.

When the LPA arrived at 3:00 PM there were six (6) clients and five (5) staff present. The home is vendored by TCRC as a level 6-I home.



The purpose of today's inspection is to follow up on a self reported incident that occurred on April 14, 2024 where it was reported that two (2) staff (S1,S2) used a two (2) Man Pro-Act assist on Client #1 (C1). During today's visit LPA Cortez interviewed two clients, including C1, the administrator and one (1) staff. Interviews revealed that C1 has been provided support and has no concerns.

No immediate health and safety concerns were observed during today's inspection. The report was issued to Administrator Erik Miranda.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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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