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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197605266
Report Date: 10/12/2024
Date Signed: 10/12/2024 04:10:52 PM

Document Has Been Signed on 10/12/2024 04:10 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:JMJ GUEST HOMEFACILITY NUMBER:
197605266
ADMINISTRATOR/
DIRECTOR:		LUCIA DELA REAFACILITY TYPE:
740
ADDRESS:43905 ELM AVENUETELEPHONE:
(661) 940-5550
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 4DATE:
10/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:14 PM
MET WITH:Lucia Dela Rea - AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Gary Tan, met with Administrator Lucia Dela Rea for a One (1) Year Required visit for this facility. LPA arrived and was greeted by staff Eric Padua and explained the reason for the visit. Ms. Dela Rea arrived within three (3) minutes.

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 Mitigation and Infection 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.

A tour of the physical plant was conducted with the administrator at 1:25 PM. The facility is a single storey building with six (6) bedrooms and three (3) bathrooms currently occupying four (4) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents. Hospice waiver for six (6) 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. The smoke detector is hardwired and inter connected, tested and observed to be operational. The fire extinguisher is located in the kitchen and was observed to be full and last bought on 07/21/24. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2024
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: JMJ GUEST HOME
FACILITY NUMBER: 197605266
VISIT DATE: 10/12/2024
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The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is small fountain located at the backyard but has no water. The garage is attached to the home and also being used as storage and laundry area. Laundry detergents, cleaning solutions and other toxins are locked in the cabinet and inaccessible to residents.
Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Dishwashing liquids and other cleaning supplies were stored in the kitchen cabinet and observed to be locked and inaccessible to residents. All sharps and knives were also observed to be locked in a kitchen drawer.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit to non-private rooms. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Rooms: Staff room is 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. The hot water temperature measured at 110.6.°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.



Medications: LPA observed medication in the kitchen 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 medication cabinet.

Client records: All four (4) client records are reviewed. Client records appeared to be complete and updated. Staff records: Staff record appeared to be complete and updated.

Disaster drill was last conducted on 10/07/2024. 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: 10/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2024
LIC809 (FAS) - (06/04)
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