197610610-7-29-2024-31-AS-HRAI-D7MQAV-20240729120033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610610
Report Date: 07/29/2024
Date Signed: 07/29/2024 12:01:05 PM

Document Has Been Signed on 07/29/2024 12:01 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:	CJ'S ELDER HOME		FACILITY NUMBER:	197610610
ADMINISTRATOR/ DIRECTOR:	OLIVER DOMINGO		FACILITY TYPE:	740
ADDRESS:	18718 SATICOY STREET		TELEPHONE:	(818) 294-9129
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 6		CENSUS: 0	DATE:	07/29/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:55 AM
MET WITH:	Madonna Olila, Licensee		TIME VISIT/ INSPECTION COMPLETED:	12:30 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

At 09:55 am, Licensing Program Analyst (LPA), Huma Rahimi conducted an announced Pre-Licensing visit to the above facility and met with Madonna Olila, Licensee, and explained the reason for the visit. At the time of this visit LPA did not observe any residents present in the facility. Fire Clearance dated 06/21/2024 and received for four (4) Non-ambulatory, one (1) Ambulatory, and one (1) Bedridden (room #3) residents. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, and a sink. Stove was observed in a good working condition. At 09:25am, LPA observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. Fire Extinguisher was last purchased on 06/20/2024 and was observed hanging on the wall in the kitchen.

MEDICATION ROOM: The centrally stored medication will be kept in the kitchen in a locked cabinet. At 10:10 AM, LPA observed the cabinet locked during the time of the visit. Residents and staff files will be kept locked in the kitchen cabinet.

BEDROOMS: There are four (4) bedrooms designated for resident’s use. Bedrooms number two (2) and three (3) are shared with an attached bathroom. Bedroom (3) is used for a bedridden resident. Bedrooms (1) and four (4) are private. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational. Facility will have a no live-in staff at the facility; however, the staff will live in the ADU unit in the back of the property.
Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

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 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: CJ'S ELDER HOME	FACILITY NUMBER: 197610610
	VISIT DATE: 07/29/2024

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

BATHROOMS: There are three (3) bathrooms at the facility of which two are attached with bedroom number (2) and (3). One of the bathrooms are in the main hallway which can be used by visitors and staff. LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and had non-skid mat The water temperature was noted at 111°.

LAUNDRY ROOM: The laundry room is located towards the end of the hallway. Laundry and other cleaning supplies are kept inaccessible in a cabinet in the laundry room. LPA observed the laundry room to be locked and inaccessible to residents in care. The washer/dryer appear to be in good working condition.

COMMON AREAS: The facility maintains a comfortable temperature at 76°F. The living room and dining area
appeared clean and were properly furnished and has a television. No obstructions and or tripping hazards throughout the facility. LPA observed a screened fireplace. LPA observed a working landline for the facility.

SURROUNDING GROUNDS: The back of the facility has sufficient yard space. LPA did observe appropriate outdoor furniture in the front yard of the facility that can accommodate five (5) residents, LPA observe a covered shaded area for residents. There is no swimming pool or any bodies of water at the facility. The exit was free of any obstruction or hazard. The facility has an ADU unit (Staff House) and LPA observed to be locked and inaccessible to residents in care. LPA did not observe any obstruction or hazard in the ADU unit.

Garage/Storage: LPA observed a parked vehicle in the garage and extra supplies (paints, some extra tables/furniture) stored. LPA observed the garage to be locked during the visit.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 11:09 AM, they were tested and observed to be operational.

Component III was conducted with the Licensee/Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2