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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802466
Report Date: 03/16/2023
Date Signed: 03/16/2023 07:30:50 PM

Substantiated


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
03/07/2023 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20230307111341
FACILITY NAME:JJ RESIDENTIAL CARE IIFACILITY NUMBER:
565802466
ADMINISTRATOR:BANAS, LORENZOFACILITY TYPE:
735
ADDRESS:1542 DEANNA AVETELEPHONE:
(805) 791-3260
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:4CENSUS: 4DATE:
03/16/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lorenzo BanasTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure client's bed was maintained in good repair
Facility is not kept free of insects
Chemical substances not secured
Missing person's plan not completed for residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
A complaint visit to investigate the above allegations. Licensing Program Analyst met with staff upon arrival and observed three (3) staff and two (2) clients present. Administrator Lorenso Banas was contacted and arrive to facility at approximatelynd 11am. LPA toured the facility with staff at approximately 10:45am and observed the following: Client #1's room observed unkept with strong bad odor; client #1's bed mattress not not clean and not maintained in good repair. Hygien products ket in a cabinet in the hallway observed unsecured; cabinet does have a lock however the cabinet does not close properly leaving a gab making chemical supplies accessible through the open area. LPA observed Orkin supply placed throught the facility for bugs. Interview conducted with staff at approximately 11am confirmed that facility does have an issue with roaches. Administrator was informed to follow up with pest control and provide a plan to maintain service appropriate to ractify the bug issue of the facility. Regarding allegation "Missing person's plan not completed for clients" Administrator stated that he does not have that plan on file for the clients. Based on the above information gathered allegations are substantiated at this time. Following deficiencies observed cited. Exit interview held. Copy of report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
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 4
Control Number 29-AS-20230307111341
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: JJ RESIDENTIAL CARE II
FACILITY NUMBER: 565802466
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited
CCR
85088(c)(1)
1
2
3
4
5
6
7
Fixtures, Furniture, Equipment and Supplies:(c)The licensee shall ensure provision to each client of the following furniture...(1)An individual bed...., maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). This requirement is not met by:
1
2
3
4
5
6
7
Administrator stated that a new mattress is order and will be arriving Friday 3/17/2023.
Submit photo of client #1's new mattress upon arrival and set up by 3/17/2023.
8
9
10
11
12
13
14
Based on observation of clients #1's room it was observed that the mattress was not maintained in good repair. This poses a potential health and safety risk to clients in care.
8
9
10
11
12
13
14
Type B
03/23/2023
Section Cited
CCR
82087(a)(1)
1
2
3
4
5
6
7
Buildings and Grounds: (a)The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1)The licensee shall take measures to keep the site free of flies and other insects. This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator agreed to provide proof of exterminator service conducted for the facility; provide plan to ensure facility is maintained free of insects and provide proof of the wall patching/painting in client #1's room. Submit plan of correction by 3/23/2023
8
9
10
11
12
13
14
Based on physical plant tour following was observed: Client #1's room wall observed with a hole and room observed not clean with bad odor; interview with staff confirmed facility has an issue with insects in the home. This poses a potiential health and safety risk to clients.
8
9
10
11
12
13
14
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: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20230307111341
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: JJ RESIDENTIAL CARE II
FACILITY NUMBER: 565802466
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/16/2023
Section Cited
CCR
82087(a)(3)
1
2
3
4
5
6
7
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where
1
2
3
4
5
6
7
Administrator moved chemical containing items to a secured cabinret during visit.
8
9
10
11
12
13
14
inaccessible to clients. This requirement is not met as evidence by:
Based on physical plant tour hygien products observed stored in a cabinet which was locked but not secured properly. This poses a potiential health and safet risk to clients in care.
8
9
10
11
12
13
14
Type B
03/23/2023
Section Cited
HSC
1507.15
1
2
3
4
5
6
7
Absentee notification plan for missing residents or participants -Every community care facility that provides adult residential care or offers an adult day program shall, for the purpose of addressing issues that arise when an adult resident or adult day program participant is missing from the f
1
2
3
4
5
6
7
Administrator agreed to develop and maintain the plan with each client. Submit self-certification that the plans are developed and maintained in each resident file by 3/23/23.
8
9
10
11
12
13
14
facility, develop and comply with an absentee notification plan for each resident or participant. The plan shall be part of the written Needs and Services Plan...
This requirement is not met as evidence by:
Based on interview with Administrator - they do not have a missing persons plan..
8
9
10
11
12
13
14
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: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4