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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801897
Report Date: 07/02/2024
Date Signed: 07/02/2024 05:03:47 PM

Document Has Been Signed on 07/02/2024 05:03 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:
07/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:Erik MirandaTIME VISIT/
INSPECTION COMPLETED:
05:05 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 staff and the reason for the visit was explained. The LPA was informed that the facility is currently experiencing a COVID outbreak. Administrators Erik Miranda and Maria Miranda arrived shortly thereafter.

When the LPA arrived at 3:50 PM there were five (5) clients and five (5) staff present. The home is vendored by TCRC as a level 4- home.



The purpose of today's inspection is to follow up on a Special Incident Report (SIR) and Report of Suspected Dependent Adult Abuse Report (SOC341) pertaining to Client #1 (C1) and Client#2 (C2). The alleged incident occurred on 06/24/2024. During today's visit LPA Cortez interviewed both Administrators and C1.

The LPA has determined further investigation is needed. Exit interview conducted with administrators. A copy of the report will be emailed to the licensee's facility email address.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2024
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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