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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602074
Report Date: 12/07/2024
Date Signed: 12/07/2024 03:57:44 PM

Document Has Been Signed on 12/07/2024 03:57 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:J & S HOME CARE IIFACILITY NUMBER:
197602074
ADMINISTRATOR/
DIRECTOR:		SOFIA ALVAREZFACILITY TYPE:
740
ADDRESS:9950 WILBUR AVENUETELEPHONE:
(818) 886-4286
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 5DATE:
12/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:21 PM
MET WITH:Sofia Alvarez - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Gary Tan met with Administrator Sofia Alvarez for a One (1) year required visit for this facility. LPA explained the reason for the visit.

A tour of the physical plant was conducted at 12:35 PM and the following was noted:

There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted indoors.. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has four (4) bedrooms and two (2) bathrooms currently occupying five (5) residents. An additional one (1) bedroom and one (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory resident. Hospice waiver for three (3) residents.
Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings and doors were checked, the following was noted:
Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 75°F. Dual smoke/carbon monoxide alarms were tested and observed to be operational. There are fire extinguisher located in the kitchen and living room, they were observed to be full and last bought on 12/07/24.
The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. There is a locked tool shed at the far end of the backyard. (continued on LIC 9099-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: J & S HOME CARE II
FACILITY NUMBER: 197602074
VISIT DATE: 12/07/2024
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The garage is attached to the house and observed to be locked, it has to go through the staff room to get into the garage. It is also being used as storage for miscellaneous supplies , PPE and old equipment. Laundry room is located adjacent to the kitchen going to the staff room and garage. All the laundry detergents, cleaning solutions, toxins and other chemicals are observed to be locked in the laundry room and inaccessible to residents.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days of non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All sharps and knives were also observed to be locked in the kitchen cabinet below the sink. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Rooms: Could only be accessed through the Laundry Room and observed to be locked. No medications are observed in the staff room.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. Sink in the bathrooms were removed and under construction. The hot water temperature measured at a range 109.1°F to 113.8°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.



Medications: LPA observed medication in the dining area cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the living room cabinet.

Client records: Client records are reviewed. all residents' file appeared to be complete and updated.
Staff records: LPA conducted a complete file review of staff records. Staff records appear to be complete and updated.

Disaster drill was last conducted on 11/12/24. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2024
LIC809 (FAS) - (06/04)
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