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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801897
Report Date: 02/20/2025
Date Signed: 02/20/2025 01:56:39 PM

Document Has Been Signed on 02/20/2025 01:56 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:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Erik Miranda, Administrator TIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 10:00 a.m., the LPA met with staff and explained the reason for the visit. At 10:45 a.m., Administrator Erik Miranda arrived at the facility. The facility is vendored by Tri-Counties Regional Center as a level 4I home.

RECORD REVIEW: Between 10:13 a.m. and 11:50 a.m., the LPA conducted a file review for all six (6) clients and six (6) staff and observed the following: Staff have current first aid. Client records were reviewed for, but not limited to current Individual Programming Plan (IPP), medical records, P & I funds, admissions agreement, and consent forms. All files were in order. The last emergency disaster / fire drill took place on 01/04/2025. Administrator’s Certificate is valid until 02/24/2026.

Starting 12:50 p.m., the LPA conducted a review of medication and medication documentation with the Administrator for three (3) clients and observed that medications were properly documented and assisted as prescribed.

Starting at 1:13 p.m., the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards.

KITCHEN: The LPA observed the kitchen and dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:13 p.m., hot water temperature measured at 105.5-degree Fahrenheit. Knives are stored in a locked kitchen drawer.

Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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: 02/20/2025
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BEDROOMS: There are four (4) client bedrooms. The LPA observed client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

RESTROOMS: Client restrooms are relatively clean and sanitary and in operating condition. Hot water temperature measured within required range. The sinks had sufficient liquid soap, and paper towels.

OUTDOOR SPACE: The LPA observed the back patio which has a covered outdoor area for client use. There are no bodies of water on the premises. Passageways were free and clear from obstruction. GARAGE: The garage is attached to the house. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage. The laundry units are located inside the garage.

COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 01/15/2025. Signs are posted throughout facility to promote handwashing. At 11:40 a.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Facility telephone was observed during the time of the visit. Medications and first aid are located inside a locked filing cabinet in the living area.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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