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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605258
Report Date: 02/04/2025
Date Signed: 02/04/2025 04:11:27 PM

Document Has Been Signed on 02/04/2025 04:11 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:JENNIFER HOMEFACILITY NUMBER:
197605258
ADMINISTRATOR/
DIRECTOR:		MARY JANE RAFANANFACILITY TYPE:
740
ADDRESS:24401 JENNIFER PLACETELEPHONE:
(661) 254-7476
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY: 6CENSUS: 6DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Suzette Tamayo- AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:50 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
On 2/04/2025 at approximately 09:40 AM, Licensing Program Analyst (LPA), Angelica Segovia conducted an unannounced annual visit to the facility. LPA was greeted by Administrator Suzette Tamayo. LPA stated the reason for their visit.

LPA asked for census, Staff/Resident Roster, and Insurance. LPA conducted a physical plant tour at approximately 11:00 AM and the following was noted:

There is only one entrance being utilized at the facility. The facility is a single unit building with five (5) bedrooms and two (2) bathrooms currently occupying six (6) residents. There is no designated staff room. The facility has approved fire clearance for six (6) non-ambulatory residents. Hospice waiver approved for one (1). Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available.

Common areas: Living room and dining room observed to be neat, clean, and organized. Both rooms observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 73°F. Fire extinguisher located in the kitchen and dated 07/30/24. Required postings such as See/Say Something, Long-Term Ombudsman, and Resident’s Rights are located aside the dining room. Fireplace: Observed to be covered and inaccessible to residents. Working telephone observed.

Kitchen: Kitchen observed to be clean and inaccessible to pests. Sufficient supplies of seven (7) day nonperishable food and two (2) day perishable foods were observed. Knives and sharps observed to be locked in bottom kitchen cabinet. Kitchen appliances observed to be working and in proper condition. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: JENNIFER HOME
FACILITY NUMBER: 197605258
VISIT DATE: 02/04/2025
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
Bedrooms: The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Extra linens/covers stored in storage closet located in hallway’s passageway.

Bathrooms: Bathrooms were checked for cleanliness and proper operation. Appropriate grab rails and skid mats were observed and in proper condition. The hot water temperature was measured within regulations at 115.0°F.

Garage: The garage can be accessed from inside the facility and is kept locked. LPA observed locked storage cabinets within the garage used to store cleaning solutions, toxins, and laundry detergents. Extra refrigerator and freezer stocked with additional food for residents. Laundry Room: The laundry room is located inside the garage. Laundry appliances observed to be working and in proper condition.

Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. There is no body of water in this facility. Locked storage unit observed. The front of the facility is also equipped with a seating area for residents.

Medications: Medication logs and facility files kept stored in locked filing cabinet aside the kitchen. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and manual.

Smoke detectors and carbon monoxide observed to be working properly and were tested. Last Fire Drill conducted on 10/25/24.

Resident/Staff Records: LPA conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated.

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
Page: 2 of 2