<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802413
Report Date: 11/14/2023
Date Signed: 11/27/2023 10:08:42 AM

Document Has Been Signed on 11/27/2023 10:08 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JD RESIDENTIAL CAREFACILITY NUMBER:
565802413
ADMINISTRATOR:JUNIO, JOJI JOSEFA BFACILITY TYPE:
735
ADDRESS:2199 MARVEL AVETELEPHONE:
(310) 435-9822
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 4DATE:
11/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Joji JunioTIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with staff. Administrator was contacted and arrived to facility shortly after. Reason for visit was explained. The LPA and staff toured the physical plant areas inside and outside with staff at approximately 1pm.

KITCHEN: Knives and cleaning supplies are stored in a locked cabinet under the sink. Kitchen appliances appeared to be in operable condition. Perishable and non-perishable food appeared sufficient. BEDROOMS: The LPA observed four single-occupancy client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms observed clean and sanitary and in operating condition. Hot water temperature measured at 135*f in the restroom used by clients at approximately 1:15pm. Hot water temperature was immediately adjusted by the owner. LPA retested the hot water temperature towards the end of the visit at approximately 4:15pm and it read 128*f. COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. Required postings observed on the wall in the common area and at the entrance. The backyard has a covered outdoor area with furniture for resident use. There is a self-latching gate on the side of the facility. There is a gated pool in the backyard, which was locked during visit. There is an ADU on the property separate from the facility. Individuals renting are fingerprint cleared. Between approximately 1:30pm -2:30pm, Staff files were reviewed. All required personal forms observed on file. Staff #1's CPI training certificate expired 8/2023. Between 2:30pm-3:30pm, client medication procedures, storage and administration logs observed; Medications observed stored locked and inaccessible in the kitchen area; Medications appeared to be dispensed according to physician orders. PRN authorization letters observed on file. Client files reviewed from 3:30pm-4pm. Client files have current needs and serves plan; physician report, admission agreement.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited Exit Interview Conducted. Copy of report and appeal rights provide.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/27/2023 10:08 AM - It Cannot Be Edited


Created By: Zabel Chochian On 11/14/2023 at 05:01 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: JD RESIDENTIAL CARE
FACILITY NUMBER: 565802413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Hot water temperature measured at 135 degrees F. Owner adjusted the temerature however it was still hot (128*F) towards the end of the visit which poses a potential safety risk to persons in care.
POC Due Date: 11/21/2023
Plan of Correction
1
2
3
4
Licensee/Adminsitrator agrees to have staff test the hot water temperature for one week three times a day to ensure that the teperature maintains within required range (105*F-120*F).
Type B
Section Cited
CCR
85165(b)(2)
Emergency Intervention Staff Training
(b) Staff who use, participate in, approve or provide visual checks of manual restraint or seclusion, shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training. (2) Staff shall maintain valid certification.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 4 staff files reviewed, staff #1's CPI training observed expired on 8/27/2023 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2023
Plan of Correction
1
2
3
4
Licensee/Administrator stated they will provide proof of training and valid certificate for staff #1 to comply with the above.
proof of correction shall be subited by 11/21/2023.
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:Desaree Perera
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2