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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801897
Report Date: 02/26/2024
Date Signed: 02/26/2024 01:21:35 PM

Document Has Been Signed on 02/26/2024 01:21 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:
02/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Joemar OngTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted a Case Management - Incident visit to follow up, and issue final findings and citations related to the initial Case Management - Incident visit conducted on 02/21/2024. The LPA was joined by Tri-Counties Regional Center (TCRC) Quality Assurance Specialists (QAS) Katy Robison. The LPA met with Co-Administrator Joemar Ong and informed him of the reason for the visit.

On 02/21/2024, LPA Cortez conducted an unannounced Case Management - Incident visit to the above facility. The purpose of the visit was to follow up on three 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 Centerc(TCRC) Quality Assurance Specialists (QAS) Katy Robison and Patrick Brown. The LPA met with Co-Administrator Joemar Ong and informed him of the reason for the 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 recordings regarding C3 and S2 was reviewed with the Co-Administrator. During today's visit the LPA and QAS interviewed Administrator Erik Miranda, one (1) client and one (1) staff.

The first self reported Unusual Incident/Injury Report (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). It was reported that S1 pushed C1. During today's visit S1 admitted to pushing C1 on their chest.

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). It was reported that C2 had a quarter size bluish discoloration on their left upper arm and that C2 alleged a peer had hurt him. Staff interviews revealed that both clients have one to ones and that nobody witnessed C2 being hurt by a peer or anybody else.
Report will continue on LIC809-C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2024
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: 02/26/2024
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The self reported Unusual Incident/Injury Report (LIC 624) received on 2/14/24 pertains to an incident regarding C3 and S2 that was video recorded by S1. It was reported that S1 had a video of S2 abusing C3. On 2/15/24 Administrator Joemar Ong sent three video recordings via text message to LPA Cortez. On 2/21/24, the video recordings regarding C3 and S2 were reviewed with the Co-Administrator with the LPA and QAS, the date the videos were recorded is unknown. The video recordings show C3 and a staff who has been alleged to be S2 in the living room of the facility. In the video, C3 is seen cornered and S2 is speaking to C3 in a very loud tone, holding a cup with a drink over C3, and C3 is heard continuously repeating "no, no, no". The Co-administrator described the recordings as S2 intimidating C3 and stated they had no knowledge of the incident or video until it was reported to him on 2/14/24 and they submitted the LIC624 to CCL. During an interview with S1, S1 admitted to recording the video and not reporting it to their administrator, licensing, or anyone else. Interview with S1 also revealed the date the video was taken is unknown, however they stated the video is not from this year but not older than 2021 when they started working at the facility. QAS Robison and LPA Cortez reminded S1 they are a mandated reporter and that any inappropriate behavior should be reported.

During the course of the investigation, on 2/21/24, C3 alleged that a staff member (S3) had kicked them. Co-Administrator Joemar placed S3 on an administrative leave and submitted a self reported Unusual Incident/Injury report to CCL on 2/21/23. Administrator Erick revealed today that C3, had confessed to them on 2/22/24 that S3 had not kicked them and that C3 had kicked S3 because they did not like them. During todays visit C3 recanted their statement and stated that they were the one who kicked S3 because they do not like them.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D)
Exit interview conducted, appeal rights and a copy of this report was issued to Administrator Joemar Ong.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Esther Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/26/2024 01:21 PM - It Cannot Be Edited


Created By: Esther Cortez On 02/26/2024 at 11:48 AM
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: 02/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/27/2024
Section Cited
CCR
80072(a)(3)

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87468.1Personal Rights of Residents in All Facilities (a)(3)To be free from punishment, humiliation, intimidation, abuse, or other actions...interfering with daily living functions such as eating, sleeping, or elimination.This requirement is not met as evidence by:
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Co-Administrator Joemar Ong stated S1 will be terminated. Administrator has agreed to dedvelop a plan how they are going to ensure the health and safety of the residents and provide to the LPA by the end of day on 2/27/2024.
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Based on intervierviews, videos and S1's admission the licensee did not comply with the above cited section as S1 admitted to pushing C1, and there is a video showing S2 abusive actions towards C3 suchs as intimidating, which poses an immidiate personal rights risk to residents in care.
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Type A
02/27/2024
Section Cited
CCR80072(a)(1)

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87468.1(a)(1) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff...This requirment was not met as evidence by:
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S2 is currently on an admistrative leave. Administrator Joemar Ong has agreed to develop a plan how they are going to ensure the health and safety of the residents in care and how they are going to ensure their personal rights are not bing infringed upon and submit by 2/27/24.
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Based on interviews and video recordings. The licensee did not comply with the cited section as video shows S2 abusive actions towards C3 and the manner S2 spoke to C3 which poses an immidiate personal rights risk to residents in care.
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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: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/26/2024 01:21 PM - It Cannot Be Edited


Created By: Esther Cortez On 02/26/2024 at 12:25 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: 02/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2024
Section Cited
CCR
80061(b)(1)(E)

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80061(b)(1)(E) Reporting Requirements. (b) Upon the occurrence.....a report shall be made to the licensing agency....(E)Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement is not met as evidenced by:
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Administrator has agreed to do an all staff traning regarding Mandated reporting requirements. and submit proof by 7/11/24.
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Based on interviews and records review, the licensee did not comply with the section cited above as the actions of S2 in the video were not reported to CCL within 7 days,S1 admitted the video is more than 3 months old which poses a potental health and safety risk to residents in care.
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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: 02/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024


LIC809 (FAS) - (06/04)
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