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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801514
Report Date: 12/10/2024
Date Signed: 12/13/2024 11:14:51 AM

Document Has Been Signed on 12/13/2024 11:14 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JJ RESIDENTIAL CAREFACILITY NUMBER:
565801514
ADMINISTRATOR/
DIRECTOR:		JOJI JOSEFA B. JUNIOFACILITY TYPE:
735
ADDRESS:930 GRANBY AVENUETELEPHONE:
(805) 842-1441
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 6DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:29 AM
MET WITH:Joji Josefa JunioTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 11:29 AM. LPA met with facility backup Administrator who contacted facility Administrator Joji Josefa Junio via telephone call. Facility Administrator arrived to the facility at approximately 11:50 AM Entrance interview conducted and the reason for the visit was explained.

Beginning at 11:30 AM, the LPA, along with the facility backup Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

BEDROOMS: There are four (4) bedrooms in the facility; all are designated for resident use. All four (4) resident bedrooms are shared rooms. LPA and the facility Backup Administrator toured all four (4) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, emergency flashlights, and sufficient lighting.

BATHROOMS: There are two (2) bathrooms at the facility. Both are designated as a common resident bathrooms. All bathrooms were observed to be clean and were equipped with nonskid surfaces. LPA observed one (1) bathroom to contain two (2) locked cabinets. The cabinets contained cleaning supplies and extra linens. The water temperature was measured in all bathrooms between 131.4 degrees Fahrenheit and 131.5 degrees Fahrenheit which is outside of the range required by regulation.

OUTDOOR SPACE: The facility has two (2) emergency exit gates, LPA observed clear passageways for emergency exit use. The facility has adequate shaded outdoor seating for resident use. LPA observed an appropriately secured shed to contain gardening and household tools. LPA observed the backyard to contain an appropriately fenced off pool that was empty of water at the time of the visit. LPA observed the doorknob on the exit from the facility to the backyard to be not properly secured to the door.


Continued on LIC 809C.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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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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: JJ RESIDENTIAL CARE
FACILITY NUMBER: 565801514
VISIT DATE: 12/10/2024
NARRATIVE
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KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured cabinet to contain knives and other sharp objects that were stored alongside detergents, soaps, and other cleaning chemicals. The LPA observed a fire extinguisher to be fully charged and purchased on 09/15/2024.

GARAGE: LPA observed the garage to contain two (2) extra refrigerators, a washer and dryer, adequate emergency food and water supplies, and a locked storage cabinet. The cabinet was observed to contain cleaning supplies and chemicals.

COMMON AREAS: This includes the living room, dining room, and hallway. LPA observed the living room to be clean and properly furnished at the time of the visit. LPA observed the living room to contain a couch, television, and activities for resident use. The dining room was observed to be clean and contains adequate seating for resident use. The hallway was observed to contain one (1) properly secured closet. The secured closet contained resident medications, first aid supplies, and activity supplies. Smoke detectors and carbon monoxide detectors were tested at 11:48 AM and were functional at the time of the visit.

Due to time constraints an LPA will return at a later date to complete the annual inspection for the facility.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited. (refer to LIC 809-Ds): Exit interview conducted and copy of the report was issued and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/13/2024 11:14 AM - It Cannot Be Edited


Created By: Trevor Byrne On 12/10/2024 at 12:24 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 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 as both resident bathrooms were measured above 131 degrees which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/11/2024
Plan of Correction
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Licensee will submit proof of water temparature between 105 and 120 degrees in the resident bathrooms to CCLD no later than POC due date.
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.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/13/2024 11:14 AM - It Cannot Be Edited


Created By: Trevor Byrne On 12/10/2024 at 12:24 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the doorknob to the backyard of the facility is not properly secured to the door which poses a potential safety risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Licensee will submit proof of appropriately secured doorknob to CCLD no later than POC due date.
Type B
Section Cited
CCR
80076(a)(15)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (15) Pesticides and other similar toxic substances shall not be stored in food storerooms, kitchen areas, food preparation areas, or areas where kitchen equipment or utensils are stored.

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 as the facility knives are stored under the kitchen sink next to detergents, soaps, and other cleaning supplies which poses a potential health risk to persons in care.
POC Due Date: 12/24/2024
Plan of Correction
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Licensee will relocate either the knives or the chemicals to an appropriate storage location and will submit proof to CCLD no later than POC due date.
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:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


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