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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850351
Report Date: 03/07/2024
Date Signed: 03/07/2024 01:28:51 PM


Document Has Been Signed on 03/07/2024 01:28 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: 3DATE:
03/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Elizabeth G. Mangune- Co Administrator TIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Co-Administrator Elizabeth G. Mangune and explained the reason for the visit. Entrance interview conducted.

The reason for today's inspection is to follow up on a self-reported death report received on 03/04/2024. The report pertains to the death of Resident #1 (R1). Per the information received, the circumstances surrounding the death of Resident #1 on 03/01/2024 may be questionable and needs to be investigated. It was reported R1 was sent to the hospital on February 27th and passed away on March 1st due to septic shock at the hospital.

During today's visit, the LPA conducted an interview with Administrator Mangune, conducted a brief tour of the facility and obtained copies of pertinent documents.

This incident was referred to Community Care Licensing Investigations Branch (IB) for review. Further investigation is required prior to issuing findings. An investigator or the LPA will return at a later date.

Exit interview conducted. A copy of the report was issued to the Administrator Mangune.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
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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