306002719-9-9-2025-22-AS-SSAS-DLLNBZ-20250917101959

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306002719
Report Date: 09/09/2025
Date Signed: 09/09/2025 02:53:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/30/2022 and conducted by Evaluator Ruth Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220630131623

FACILITY NAME:	J & S HOME		FACILITY NUMBER:	306002719
ADMINISTRATOR:	JOSE D. VILLAREAL		FACILITY TYPE:	735
ADDRESS:	11672 POES STREET		TELEPHONE:	(714) 636-5219
CITY:	ANAHEIM	STATE: CA	ZIP CODE:	92804
CAPACITY:	5	CENSUS: 4	DATE:	09/09/2025
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Jose Villareal		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Client sustained multiple injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit to the facility to conclude the investigation to the above identified complaint allegation. LPA arrived at the facility and was greeted at the door and granted entry. LPA spoke with Jose Villareal, Licensee and explained the purpose of the visit.

Findings are based upon this investigation which included facility file review, and interviews conducted.
It is alleged that client sustained multiple injuries, specifically to scratches and redness in the fingers, knees, forehead and ear lobes. Record review revealed that CCLD received an incident report from the facility indicating that client (C1) began displaying episodes of intense episodes of shouting and scratching the walls. C1 used their hands, banged their head on the wall and headboard of their bed, and used their legs/knees to push forward. Erratic and aggressive behavior began on June 28, 2022, to the morning of June 29, 2022. Positive support plans dated May 14, 2022, indicated targeted behavior, emotional outburst
Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220630131623

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: J & S HOME	FACILITY NUMBER: 306002719
	VISIT DATE: 09/09/2025

NARRATIVE

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resistiveness, physical aggression and self-talk, antecedents to behavior C1 is most likely to exhibit this behavior when they do not get what they want when they want it or when they are frustrated or angry about something. C1 may do this when feeling anxious which may cause to lash out at anyone in front of them due to negative thoughts or voices they are fighting in their head. Physical aggression winding their fist up and threatening to hit. Semi annual progress report dated November 9, 2021, A huge frustration for C1 was not being able to go out due to covid19. C1 is nonverbal and only uses short sentences. C1 appears to have learned that they are able to get what they want when they exhibit behaviors. Interview with staff stated that when C1 gets upset part of their behavior is biting their knuckles, fingernails, bang their head on the wall, and yelling/cursing. The night of June 28, 2022, C1 was upset because they had not been able to go to day program and they were banging on the walls, yelling, fighting, and hitting walls with their fist. Facility has added safety measures in C1’s room and to their hands. Staff can de-escalate the situation, but recently C1 has developed a new behavior or fighting, yelling and cursing to their self. It was reported to their primary doctor and C1 is due for a visit to evaluate the change.

Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated.

An exit interview was conducted with the facility representative and a copy of this LIC9099 report was left at facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025

LIC9099 (FAS) - (06/04)

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