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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850351
Report Date: 01/08/2024
Date Signed: 01/08/2024 02:51:35 PM


Document Has Been Signed on 01/08/2024 02:51 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:
01/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Elizabeth Mangune- StaffTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Esther Cortez conducted an unannounced Case Management -Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20240105155510). The purpose of the visit is to issue citations for deficiency observed during the complaint investigation which is not related to the complaint. Administrator Rodolfo Ohide was contacted via phone and the reason for the visit was explained. Administrator was unable to be at the facility during today’s visit and authorized staff Elizabeth Mangune to sign and receive the report.

When the LPA arrived at the facility at 10:20 a.m., the LPA observed one staff member (S1) removing residents’ medications from original containers and placing them in small containers, preparing the medications for the whole week, more than 24-Hours in advance. Upon observation, S1 stated they will no longer pre-pour medications for more than 24 hours in advance.

At approximately 10:50 a.m., the LPA toured the physical plant, interviewed the administrator over the phone, conducted a file review, and obtained copies of pertinent documents. Prior to the visit, the LPA printed out the facility personnel report summary from the Licensing Information System (LIS). Per record review, conducted by the LPA on the Guardian Background Check System website, one staff member (S2) does have fingerprint clearance but is not associated with this facility. Record review revealed that S2 has been working at this facility since June of 2023. The LPA also observed S2’s file with a blank health screening and no Tuberculosis test results.

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: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
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 3


Document Has Been Signed on 01/08/2024 02:51 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: 01/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2024
Section Cited
CCR
87355(e)(2)

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87355(e)(2) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health… shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance as specified... This requirement is not met as evidenced by:
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The licensee agrees to associate the staff to the facility immediately and submit proof by 01/09/2024. Civil penalties will continue to assess until the plan of correction is provided.
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Based on record review and interview the Licensee did not comply with the section cited by not transferring the criminal record clearance for S2 to this facility prior to employment which poses an immediate health, safety and personal rights risk to persons in care.
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Type A
01/09/2024
Section Cited
CCR87465(h)(5)

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87465 (h)(5) Incidental Medical and Dental Care:(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container..This requirement is not met as evidenced by:
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During the inspection, staff stated they will no longer pre-pour medications for more than 24 hours in advance.
Licensee agreed to review section cited and provide a statement of understanding to CCL by 1/09/2024.
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Based on observation, the licensee did not comply with the section cited above as LPA observed S1 removing residents medication from its original container and preparing for more than 24-Hours in advance, which poses an immediate health and 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: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/08/2024 02:51 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: 01/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2024
Section Cited
CCR
87411(f)

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87411(f) Personnel Requirements – General. … Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician ....
This requirement is not met as evidenced by:
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The Administrator agreed to do the following:
1. Obtain the completed health screenings and/or TB results for S2. Submit proof by 01/15/2024
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Based on file review, the licensee did not comply to the section cited above as S2 FILE had a blank health screening with no TB test results which poses a potential health and safety risk to residents 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: 01/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2024
LIC809 (FAS) - (06/04)
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