565850351-9-21-2023-29-AS-KLOZ-CYVRA9-20231226115045

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850351
Report Date: 09/21/2023
Date Signed: 09/21/2023 10:43:56 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2023 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20230919143817

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:	09/21/2023
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Rodolfo O'Hide		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Unlicensed Care

INVESTIGATION FINDINGS:

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Licensing Program Analyst Esther Cortez and Licensing Program Manager KaSandra Lopez conducted an unannounced inspection at the property today due to Community Care Licensing Division (CCLD) receiving a complaint alleging individual(s) residing at the property require care and supervision.

The parties initially met with caregiver Elizabeth Mangune and gained entry. Operator Rodolfo O’Hide was contacted at 8:45 a.m. and informed of the reason for the inspection. The Operator arrived at 9:19 AM. A physical plant tour conducted revealed the home has three resident bedrooms and one staff bedroom. There are five residents residing in the home, with one resident currently hospitalized. Observation and interviews revealed all five residents require care and supervision.

Report will continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 29-AS-20230919143817

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/21/2023

NARRATIVE

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The allegation of unlicensed care is substantiated at this time. The findings were discussed with the Operator. A Notice of Operation in Violation of Law (NOVL) was issued. The Operator understands the NOVL notifies the operator they are operating without a license which is considered a violation of the Health and Safety code 1569.10. The Operator submitted an application for licensure at this location on 03/08/2023. During today’s visit, the Operator confirmed the desire to apply for a Residential Care Facility for the Elderly (RCFE) license; therefore, the plan of correction for the citation issued is cleared. The Operator also understands the facility cannot accept any new residents until they receive an RCFE license.

Exit interview conducted. A copy of the report, appeals rights, and NOVL was provided to the Operator.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230919143817

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/21/2023 Section Cited HSC 1569.10	1 2 3 4 5 6 7	1569.10. RCFE; license or permit; necessity: No person, firm, partnership, association, or corporation... shall operate, establish, manage, conduct, or maintain a residential facility for the elderly in this state without a current valid license... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Operator submitted an application for licensure at this location on 03/08/2023 and stated that they shall not admit new residents.
	8 9 10 11 12 13 14	Based on interviews, observation and record review, the Operator did not comply with the section cited above as five (5) out of five (5) clients require supervision and are receiving assistance with aspects of care, which poses an immediate health and safety risk to tenants in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC9099 (FAS) - (06/04)

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