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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802413
Report Date: 11/05/2024
Date Signed: 11/05/2024 01:47:13 PM

Document Has Been Signed on 11/05/2024 01:47 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JD RESIDENTIAL CAREFACILITY NUMBER:
565802413
ADMINISTRATOR/
DIRECTOR:
JUNIO, JOJI JOSEFA BFACILITY TYPE:
735
ADDRESS:2199 MARVEL AVETELEPHONE:
(310) 435-9822
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 4DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Joji Josefa B Junio TIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there were no staff were available, but the  Administrator Joji Josefa B Junio,  was contacted and arrived shortly after. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. All four (4) clients were at day programs during the visit.

LPA inspected the kitchen/food service area at approx. 10:30 a.m.  Knives and sharp objects are stored in a locked cabinet underneath the sink. Cleaning supplies were observed kept underneath the sink as well. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time.

At the time of the visit, the common area furniture's were observed to be in good condition. LPA observed multiple books and activities  stored in a cabinet in the office area. A sufficient supply of PPE and toiletries were observed stored inaccessible to clients as well. LPA observed medication, first aid kit, facility records stored in the hallways closet inaccessible to residents in care. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers were serviced and tagged by fire extinguisher service company during the visit.

The LPA observed four (4)  client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The client restrooms were clean and sanitary and in operating condition.  The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit.   Office area was located to left of front entrance.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JD RESIDENTIAL CARE
FACILITY NUMBER: 565802413
VISIT DATE: 11/05/2024
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Continued from 9099
All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed to be only accessible from the exterior of the home. LPA observed garage to store an additional fridge to store extra perishable food. LPA also observed laundry area, four (4) containers of emergency food supply along with additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed two (2) self-latching gate with clear passageways clear of obstruction.  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. There is a swimming pool with a fenced enclosure. LPA observed pool to be inaccessible to clients in care.

Records review began at approx. 11:30am, four (4) client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Five (5) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.   Last emergency disaster drill was conducted 10/10/2024.

Medications review began at approx. 01:00 p.m. All medications including PRNs were labeled, stored inaccessible to residents in care. Medications were observed to be administered as prescribed at this time.

Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.
The LPA obtained the following documents at the time of visit: LIC500 Personnel Report and LIC9020 Client Roster.
 
Exit interview conducted. A copy of the report was provided to the Administrator.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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