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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801226
Report Date: 05/05/2022
Date Signed: 05/05/2022 03:47:30 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210421102410
FACILITY NAME:JAJ RESIDENTIAL CARE FOR ELDERLYFACILITY NUMBER:
405801226
ADMINISTRATOR:JOE D. CASTILLOFACILITY TYPE:
740
ADDRESS:517 LOS OSOS VALLEY ROADTELEPHONE:
(805) 528-7740
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:6CENSUS: 3DATE:
05/05/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Joe Castillo, AdministratorTIME COMPLETED:
03:54 PM
ALLEGATION(S):
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Staff do not ensure the residents are properly fed while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings. LPA met with Administrator Joe Castillo and explained the purpose of the visit.

LPA Darlene Chavez conducted an initial complaint visit on 04/23/2021. LPA Chavez requested documentation. LPA De Leon conducted an annual visit on 06/16/2021 checking on food supply around 10:30 AM. The food supply was within the requirements of regulation. LPA De Leon conducted subsequent complaint visit on 05/05/2022 at 2:00 PM. LPA checked all of the facility food supply at 2:30 PM, the facility had 2 plus days of perishable and 7 plus days on non-perishables foods for residents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
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 2
Control Number 29-AS-20210421102410
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JAJ RESIDENTIAL CARE FOR ELDERLY
FACILITY NUMBER: 405801226
VISIT DATE: 05/05/2022
NARRATIVE
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LPA verified no residents were on special diets. The facility had a back-up emergency food supply with water for residents in care. LPA interviewed Administrator at 2:50 PM and facility staff at 3:10 PM.

On the allegation: Staff do not ensure the residents are properly fed while in care. Based on LPA observation on 06/21/2021, on 05/05/2022 visits and staff interviews the facility has an adequate food supply to meet regulation requirements with residents in care. The grocery shopping is conducted weekly on Wednesdays and on Monday's to keep a fresh fruit supply on hand at all times with 2-3 fruits for variety purchased as well as maintains a supply of canned and frozen fruits. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to Administrator/Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2