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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850351
Report Date: 12/06/2023
Date Signed: 12/06/2023 04:56:35 PM


Document Has Been Signed on 12/06/2023 04:56 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:JM'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
565850351
ADMINISTRATOR:OHIDE, JOSEPHFACILITY TYPE:
740
ADDRESS:2221 KEPLER DRTELEPHONE:
(805) 202-9208
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 5DATE:
12/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Rodolfo O'hideTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted a case management - deficiencies visit to address deficiencies identified during a complaint investigation regarding complaint number 29-AS-20231129152124. LPA met with administrator Rodolfo O'Hide and explained the reason for the visit.

During today's visit at 3:05 p.m. the LPA observed a box full of prescribed medicine in bubble packs at the kitchen table unattended accessible to residents in care. During facility tour, the LPA observed prescribed medicine out in rooms 3 and 4 accessible to residents in care. The LPA observed a small container with a residents medicine pre-poured at the kitchen table accessible to residents in care. At 4:30 p.m. the LPA observed a kitchen knife out on the counter unattended accessible to residents in care. Upon observation, staff locked away all items making them inaccessible to residents in care. Facility serves residents with dementia.

Pursuant to Title 22 of the California Code of Regulations Division 6, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted, administrator sign and receive report. A copy of the report and appeal rights provided.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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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Document Has Been Signed on 12/06/2023 04:56 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/12/2023
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Staff locked away all items that posed a danger to residents in care during the visit. Administrator stated that they will provide documentation of staff training regarding regulation 87705(f)(1) to CCL by 12/12/23.
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Based on LPA's observations, the licensee did not comply with the section cited above as medication and a knife were observed accessible to residents which posed an immediate safety risk to persons 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 LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
LIC809 (FAS) - (06/04)
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