<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850351
Report Date: 06/20/2024
Date Signed: 06/20/2024 01:11:47 PM


Document Has Been Signed on 06/20/2024 01:11 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: 1DATE:
06/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Crisostomo Libutan-Caregiver TIME COMPLETED:
01:15 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
Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management -Deficiencies visit in conjunction with a subsequent 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. During today’s visit, LPA Cortez met with staff Crisostomo Libutan. 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 Crisostomo Libutan to sign and receive the report.

During the complaint investigation of complaint # 29-AS-20240105155510, the following deficiencies were observed:

Since 10/06/2023, the effective date the facility was licensed, there were no incident reports submitted for R1’s hospitalization's on 10/03/2023 PEG (Percutaneous Endoscopic Gastronomy) tube placement; 10/18/2023 intra-abdominal lysis of adhesions laparoscopic; 11/23/2023 for IV anti-biotic treatment; and 01/03/2024 for sepsis and UTI.

On 10/03/2023 R1 had a PEG tube placement due to failure to thrive. This is a prohibited health condition. During the hospital visit on 02/27/2024, R1 was documented as having a deep tissue pressure injury on sacrum and a wound on right leg, that was present on admission. R1 also had an unstageable pressure injury on their right heel and a wound on their back that were not documented as present at admission. The PEG tube and the unstageable pressure injury are prohibited health conditions and therefore an exception would be needed in order to retain R1. There were no exception requests submitted to the Department for these prohibited health conditions.

Report will continue on LIC809-C (2ND PAGE).
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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 4


Document Has Been Signed on 06/20/2024 01:11 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: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2024
Section Cited
CCR
87211(1)(B)

1
2
3
4
5
6
7
87211(a)(1)(B) Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when a resident incurs any serious injury while under facility supervision.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
The licensee will submit a plan describing how you will ensure reporting requirements are followed. Submit proof to CCL by 06/21/2024.
8
9
10
11
12
13
14
Based on records review, the licensee did not comply with the section cited above. Licensee did not submit incident reports for R1’s numerous hospital visits in 2023 and 2024, which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
06/21/2024
Section Cited
CCR87463(a)(3)

1
2
3
4
5
6
7
87463(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary...(3)Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Condition.
1
2
3
4
5
6
7
The licensee will submit a plan describing how you will ensure residents have current updated reappraisals. Submit proof to CCL by 06/21/2024

8
9
10
11
12
13
14
.This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. Licensee did not submit an updated, current resident reappraisal for R1, which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
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: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 06/20/2024 01:11 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: 06/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2024
Section Cited
CCR
87615(a)(1)(2)

1
2
3
4
5
6
7
87615(a)Persons who require health services for or have a health condition, ... shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. (2) Gastrostomy tubes. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The licensee will submit a plan describing how you will submit exception requests for prohibited health conditions. Submit proof to CCL by 06/21/2024.
8
9
10
11
12
13
14
Based on records review, the licensee did not comply with the section cited above. Licensee did not submit exception requests for R1’s prohibited health conditions (PEG tube and unstageable pressure injury), which posed an immediate health and safety risk to residents 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 LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: 06/20/2024
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
26
27
28
29
30
31
32
During the investigation, information obtained from the Tri-Counties Regional Center (TCRC) advised that TCRC has had an ongoing problem with the facility not submitting the required quarterly reports for R1’s progress. In addition, the facility did not submit an updated, current resident reappraisal for R1. The resident appraisal submitted to Community Care Licensing (CCL) was dated 03/04/2019.

Citations issued, exit interview, appeal rights given.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4