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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850609
Report Date: 12/04/2025
Date Signed: 12/04/2025 03:06:15 PM

Document Has Been Signed on 12/04/2025 03:06 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JM'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
565850609
ADMINISTRATOR/
DIRECTOR:		OHIDE, RODOLFOFACILITY TYPE:
740
ADDRESS:904 L STREETTELEPHONE:
(805) 202-9208
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 4DATE:
12/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Rodolfo OhideTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analysts (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 9:35 a.m., the LPA met with staff and explained the reason for it visit. At 9:55 a.m., the Licensee, Rodolfo Ohide arrived at the facility.

RECORD REVIEW: Between 10:04 a.m. and 12:00 p.m., the LPA conducted a file review for all four (4) residents and staff regularly scheduled and observed the following: Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. Two (2) out of four (4) residents did not have a physician’s report/ medical assessments. One (1) out of four (4) residents require updated appraisals/needs and service plan, a technical violation was issued. Three (3) out of four (4) residents require a preadmission appraisal, a technical violation was issued. Administrator’s Certificate is pending for renewal. The LPA could not identify staff records, including training records, a technical violation was issued. The LPA had several conversations with the Licensee with the goal of providing education in regard to maintaining current resident and staff records.

At 1:14 p.m., the LPA, along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards.

KITCHEN: The LPA observed the kitchen and dining area. Knives are stored in a locked kitchen cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:17 p.m., hot water measured at 107.4-degree Fahrenheit.
Continued on LIC-809-C.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Emily Peraldi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 12/04/2025 03:06 PM - It Cannot Be Edited


Created By: Emily Peraldi On 12/04/2025 at 02:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JM'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565850609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in ater temperature in the restrooms was measured at 133.0 degree F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2025
Plan of Correction
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The Licensee adjusted the temperature and will be checking the temperature and documenting it.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Emily Peraldi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/04/2025 03:06 PM - It Cannot Be Edited


Created By: Emily Peraldi On 12/04/2025 at 02:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JM'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565850609

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 4 residents require a medical assessment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2025
Plan of Correction
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The Licensee will obtain medical assessments/ physician reports for the two (2) residents.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Emily Peraldi
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2025


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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JM'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565850609
VISIT DATE: 12/04/2025
NARRATIVE
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BEDROOMS: The facility is a single-story residential home with four (4) bedrooms and two (2) bathrooms. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 1:22 p.m., the hot water temperature was measured at 133.0-degree F. The Licensee adjusted the water temperature during the time of the visit. The sinks had sufficient liquid soap, and paper towels.

OUTDOOR SPACE: At 1:14 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on each side of the house designated for an emergency exits. The garage is attached and remains inaccessible to residents. Laundry units are located inside the garage. Cleaning solutions are located inside the garage. Additional food supplies and water are also stored in the garage. There are no bodies of water on the premises.

COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 05/14/2025. At 1:27 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Night lights were present throughout the facility. All exits have functioning auditory devices and were operational at the time of the visit. Medications are located in a locked cabinet near the living area. There is a working telephone on premises. The LPA observed additional clean linens and towels in the hallway closets.

Due to time constraints the LPA will return at a later date to complete the annual.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted and copy of the report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Emily Peraldi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2025
LIC809 (FAS) - (06/04)
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