<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801514
Report Date: 02/21/2024
Date Signed: 02/26/2024 09:46:58 AM

Document Has Been Signed on 02/26/2024 09:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JJ RESIDENTIAL CAREFACILITY NUMBER:
565801514
ADMINISTRATOR:JOJI JOSEFA B. JUNIOFACILITY TYPE:
735
ADDRESS:930 GRANBY AVENUETELEPHONE:
(805) 842-1441
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 6DATE:
02/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:38 AM
MET WITH:Joji JunioTIME COMPLETED:
03:45 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
Licensing Program Analyst (LPA) Zabel Chochian made an unannounced annual required visit. LPA met with facility staff and explained the reason for this visit. Administrator was contacted and arrived shortly after.
Upon entry a physical plan tour was conducted. All smoke/carbon monoxide detectors were tested and function properly. The fire extinguisher was located in the kitchen area and appeared functional with record of service date 09/15/2023. Kitchen: The kitchen appeared clean and the appliances and fixtures functional; observed at leasts two (2) day supply of perishable and seven (7) non-perishable food at the facility; properly stored. Knives and detergents were stored in locked drawers and cabinets. LPA observed sufficient cleaning/disinfecting supplies and PPE supplies. Bedrooms: There were four (4) bedrooms total designated for residents' use; two (2) private and two (2) shared. All bedrooms observed clean, properly furnished and had sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms observed clean and properly supplied. Hot water temperature was 119 degrees Fahrenheit. Cleaning supplies observed locked in the cabinets. Common Areas: These included the living room and dining area. The common areas appeared clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. Facility has a pool that is gated and made inaccessible to clients. LPA reviewed client and staff files between 12pm-1:30pm. Client files included all required documents (admission agreement, medical assessments, Individual Program Plan, physician orders for medications and centrally stored medication logs). Staff files reviewed for regularly scheduled staff at the facility. Staff files included current first aid and CPR certifications as well as sufficient training documentation. Staff present during visit is fingerprint cleared and associated to this facility. Number of staff scheduled observed to be sufficient to meet the needs of clients present during todays visit. Medications observed locked in the storage space near the entrance. Medication records, policy and procedures reviewed with administrator at approximately 2pm-3:30pm. Medication audit revealed that administrator is not accurately recording medications, and/or missing expiration,and fill dates.
Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):
Exit interview conducted. Copy of report and appeal rights reviewed and issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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
Document Has Been Signed on 02/26/2024 09:46 AM - It Cannot Be Edited


Created By: Zabel Chochian On 02/21/2024 at 03:26 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: JJ RESIDENTIAL CARE
FACILITY NUMBER: 565801514

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on medication record review, the licensee did not comply with the section cited above in two (2) out of six (6) residents medications records reviewed revealed that administrator is not recording all of the residents' medications on the required log (centrally stored medication record). This poses a potential health, and safety risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
1
2
3
4
Administrator agreed to review all residents medication and use a centrally stored record log to records all current resident's medication on that log. Submit self-certification letter once all residents medications are reviewed and recorded according to Titile 22. Submit copy of the self certification letter and central stored record for each resident by POC due date 2/23/2024.
Type B
Section Cited
HSC
1565(e)
Other Provisions
(e) A facility shall have all of the following information readily available during an emergency:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above. Administrator stated that she does not have an emergency file set up for the residents in care. This poses a potential safety risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
1
2
3
4
Administrator agreed to separate the required forms for emergency personnel for quick acess and reference when needed.
Submit self-certification letter of understanding and completeing the task agreed on during today's visit.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2