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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802466
Report Date: 11/04/2022
Date Signed: 11/07/2022 03:57:54 PM

Document Has Been Signed on 11/07/2022 03:57 PM - 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 CARE IIFACILITY NUMBER:
565802466
ADMINISTRATOR:BANAS, LORENZOFACILITY TYPE:
735
ADDRESS:1542 DEANNA AVETELEPHONE:
8057913260
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 4DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Ramon JunioTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 11:09 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with back-up Administrator Ramon Junio and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher appeared fully charged.

KITCHEN: Knives and cleaning supplies are stored in a locked cabinet under the sink. Kitchen appliances appeared to be in operable condition. Perishable and non-perishable food appeared sufficient. LPA observed a dead cockroach behind the microwave. BEDROOMS: The LPA observed four single-occupancy client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Bedroom two had trash on the floor and LPA observed a cockroach on a game controller sitting on the desk. The client in bedroom two allowed staff to clean their room during LPA's visit. RESTROOMS: Restrooms are clean and sanitary and in operating condition. COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. Medications are stored in a locked cabinet near the living room. The LPA observed the required postings throughout the facility. The backyard patio is equipped with furniture for clients' use. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. Facility staff were not wearing masks and were instructed they must wear them at all times in the facility. The LPA observed an inadequate supply of Personal Protection Equipment (PPE). The Administrator is able to obtain additional supplies. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. Today's reports and appeal rights were discussed. A copy of the report was emailed to the Administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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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Document Has Been Signed on 11/07/2022 03:57 PM - It Cannot Be Edited


Created By: Teresa Camara On 11/04/2022 at 12:17 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 II
FACILITY NUMBER: 565802466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2022
Section Cited

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80087 Buildings 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. (1) The licensee shall take measures to keep the facility free of flies and other insects.
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This requirement is not met as evidenced by:
LPA observed a dead cockroach in the kitchen behind the microwave and a cockroach in bedroom 2, which poses a potential health, safety or personal rights risk to persons in care.
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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


LIC809 (FAS) - (06/04)
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