565850351-9-29-2023-29-AS-ECOZ-CW5SUX-20230929141151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850351
Report Date: 09/29/2023
Date Signed: 09/29/2023 02:12:40 PM

Document Has Been Signed on 09/29/2023 02:12 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:	JM'S RESIDENTIAL CARE HOME		FACILITY NUMBER:	565850351
ADMINISTRATOR:	OHIDE, JOSEPH		FACILITY TYPE:	740
ADDRESS:	2221 KEPLER DR		TELEPHONE:	(805) 202-9208
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 5	DATE:	09/29/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Rodolfo O'Hide		TIME COMPLETED:	02:20 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	At 9:00 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Rodolfo O’Hide. This is a change of ownership application. A dementia program was included in the plan of operation. A Hospice Waiver for six (6) has been requested. Component III was completed during the inspection with the applicant. The facility is one story. At 9:15 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for a capacity of six (6); five (5) non-ambulatory residents; one (1) bedridden approved for rooms #1, 3 and 4 however only for one (1) bedridden resident in the facility. The facility has zero (0) private resident bedrooms, and three (3) shared room(s), Room #1, 3, and 4. All resident rooms have direct exits to the outside. The facility does not have fire sprinklers. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. Room # 2 is a designated staff room. All rooms were free of odors. All window screens were clean and maintained in good repair. There are two (2) bathrooms in the facility. One (1) is designated as a staff bathroom; and one (1) is a resident bathroom. The resident bathroom has a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was measured as follows: resident’s bathroom = 112.2 F and the kitchen – 115.3 F, which fall within the allowable range of 105F to 120F. Report will continue LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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: JM'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 565850351
	VISIT DATE: 09/29/2023

NARRATIVE

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Resident and staff records are stored in a cabinet, which is currently located in the living area. Medications are centrally stored in a locked cabinet in the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a hallway closet.

Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in the kitchen and a locked cabinet located in the garage. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, magazines and/or activity supplies in the living room and sun room area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. All rugs contained nonslip material underneath. There is a fireplace in the living room. It is screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they do not have a central A/C, however the licensee understands that they are required to cool the rooms so that they do not exceed 85 degrees Fahrenheit.

The facility smoke alarm system is hard wired. There is a pull station at the front entry of the house. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit.
There is one (1) fire extinguishers in the house. It was fully charged and did not exceed the expiration date.
The laundry area is located in the garage.

Report will conitinue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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: JM'S RESIDENTIAL CARE HOME	FACILITY NUMBER: 565850351
	VISIT DATE: 09/29/2023

NARRATIVE

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The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in the garage. Extra incontinence supplies are stored in the garage and sun room. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted on the wall of the entryway. The emergency telephone numbers are posted on the wall of the entryway. Other required postings are posted on the wall of the entryway.

The exterior passageways were clean and clear of any obstructions. There is a canopy covered patio area at the back of the house with chairs and two small tables. The entire property is fenced. The back and sides of the house are separated from the front yard by gates at the north and south side passageways. There is no front yard gate or driveway gate. There is a gate with a self-latching mechanism for persons to enter the back yard on the left side of the house. There are two locked storage shed in the back yard. There are no bodies of water on the premises at the present time. The garage is accessible from the house; the doors were locked from the inside of the house. Toxic or danger items or tools in the garage, were locked in a cabinet during the visit.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC809 (FAS) - (06/04)

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