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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603061
Report Date: 11/02/2021
Date Signed: 11/02/2021 10:46:16 AM

Document Has Been Signed on 11/02/2021 10:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:J & S HOME CARE IIIFACILITY NUMBER:
197603061
ADMINISTRATOR:ALVAREZ, JOSEFACILITY TYPE:
740
ADDRESS:18534 CHATSWORTH STTELEPHONE:
(818) 363-3651
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY: 6CENSUS: DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Sofia AlvarezTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced annual required visit. LPA met with administrators Jose and Sofia Alvarez and explained the reason for this visit.
LPA started a physical plant tour at approximately 9:45 am.
The facility has four (4) bedrooms and two (2) bathrooms currently occupying 6 residents. There is an additional room for staff use. Smoke detectors and Carbon Monoxide detector were tested and function properly. All exit alarms on doors were tested and were observed to function properly.
Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed sufficient supply of perishable and non-perishable food at the facility; Food items were not properly stored/labeled Sharp objects are stored in a locked drawer in the kitchen.

Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. Properly labeled medications were locked in a cabinet in the hallway area.



Surrounding Grounds (Outdoors): There was a shaded area with chairs outdoor use. There is a fenced pool in the backyard.
No deficiencies cited. Exit Interview conducted.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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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