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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198600173
Report Date: 09/11/2025
Date Signed: 09/11/2025 01:35:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2025 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20250908100650
FACILITY NAME:J-J ADULT CARE HOMEFACILITY NUMBER:
198600173
ADMINISTRATOR:JOSE & JEAN TIMBOLFACILITY TYPE:
735
ADDRESS:1233 BOYNTON STREETTELEPHONE:
(818) 243-0628
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:6CENSUS: 5DATE:
09/11/2025
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Catherine AbalosTIME COMPLETED:
01:48 PM
ALLEGATION(S):
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Staff did not ensure facility was pest free.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility, met with Catherine Abalos, and explained the reason for the visit.

---Staff did not ensure facility was pest free.

It was alleged that resident observed cockroaches in the facility kitchen. To investigate the allegation, on 09/11/2025 LPA conducted a physical plant tour and requested documents at around 11:00a.m., interviewed three (03) staff and two (02) residents. During the physical plant tour, LPA did not observe any pests in the facility. A review of records shows that facility gets frequent pest control services with the most recent being 08/20/2025. During interviews with staff, two (02) out of three (03) staff confirmed cockroaches in the facility kitchen. Staff #2 (S2) added that it was a tiny cockroach found under a self cover in the kitchen cabinet.
(CONT. on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20250908100650
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: J-J ADULT CARE HOME
FACILITY NUMBER: 198600173
VISIT DATE: 09/11/2025
NARRATIVE
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During interviews with residents, one (01) out of two (02) residents stated they witnessed cockroaches in the facility but the other resident stated they did not. LPA was unable to interview one (01) out of three (03) resident currently in the facility as they were asleep.

Based on interviews, there is enough information to verify the allegation therefore the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 6 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No other health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20250908100650
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: J-J ADULT CARE HOME
FACILITY NUMBER: 198600173
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2025
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by;
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Licensee will review Title 22 80087 Buildings and Grounds and submit a written letter to the LPA stating they have read and understood the regulation and that they will adhere to it by the POC due date.
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Based on interviews, licensee did not ensure that facility is free from pests which poses a potential health, safety and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3