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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802466
Report Date: 12/06/2023
Date Signed: 12/06/2023 05:58:35 PM

Document Has Been Signed on 12/06/2023 05:58 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:
(805) 791-3260
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 4DATE:
12/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Lorenzo BanasTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct a required annual visit. Upon arrival LPA met with staff. LPA observed three (3) three staff and three (3) clients in the home. Staff reported that there are three (3) clients in the home and one (1) client is attending day program. Reason for visit was stated and staff contacted Administrator. Facility infection control practices and procedures were reviewed with Administrator and staff.

The LPA toured the physical plant areas inside and outside with staff at approximately (approx.) 10am, 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 and last serviced 02/15/2023. 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 food stored uncovered in the garage refrigerator. BEDROOMS: The LPA observed four single-occupancy client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Bedroom two (2) had a very strong bad odor. 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. Required postings observed throughout the facility. The backyard patio is equipped with furniture for clients' use.

STAFF RECORDS: At approx. 11am: Staff files reviewed included but not limited to: training records, current first aid and CPR certifications. Staff present are fingerprinted, cleared and associated to this facility.


RESIDENT RECORDS: Reviewed at approx. 12pm: resident files included admission agreements, medical assessments, personal rights, consent forms, lists of personal property, and appraisals. One (1) out of four (4) clients files was missing an updated/current needs and services plan. According to administrator the appraisal was sent to family for signature. Administrator agreed to follow up and ensure it is signed and returned promptly. A technical violation was issued for this. (continue to LIC809c page)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2023
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 12/06/2023
NARRATIVE
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Licensee handles cash for two (2) out of the four (4) clients. LPA reviewed cash resources for the two (2) clients at approx. 2:30pm. Logs and cash on hand were consistent.

Medications: Reviewed at approx.1pm. Medication administration record and centrally stored print out provided by the pharmacy is being used for record keeping. Medication storage and administration logs observed. Medications observed locked and inaccessible in the closet. PRN authorization letters observed on file.

Administrator did not have the facility Disaster Preparedness plan; last fire and earthquake drill was conducted 02/10/2023. Administrator agreed to conduct fire and earthquake drills quarterly. Administrator stated that he will complete the Emergency Disaster form (LIC610D), review with staff and submit to Community Care Licensing by 12/07/2023.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. Copy of report and appeal rights provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 12/06/2023 05:58 PM - It Cannot Be Edited


Created By: Zabel Chochian On 12/06/2023 at 04:05 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: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85065.6(b)(1)
Night Supervision
(b) Employees providing night supervision from 10:00 p.m. to 7:00 a.m., as specified in (c) through (f) below, shall be available to assist in the care and supervision of clients in the event of an emergency, and shall have received training in the following: (1) The facility's planned emergency procedures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on bservation and interview with Administrator/Licensee, the licensee did not comply with the section cited above. No training observed in the three (3) staff files reviewed on facilty's planned emergency procedures. Administrator confirmed that training was not conducted this year. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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Administrator agreed to provide training to all staff on the facility's planned emergency procedures and submit proof.
Type A
Section Cited
HSC
1565(a)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on interview and record review, the licensee did not comply with the section cited above. Administrator did not have a facility Disaster Plan during visit. This which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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4
Administrator stated that he will complete the LIC610D Emergency Disaster document for the facility, review with staff and submit copy to CCL.
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: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 12/06/2023 05:58 PM - It Cannot Be Edited


Created By: Zabel Chochian On 12/06/2023 at 04:05 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: 12/06/2023

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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2
3
4
Based on observation, the licensee did not comply with the section cited above. Room #2 had a very strong bad odor smell during visit. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator agreed to develop a plan to ensure the facility is maintained clean, safe and sanitary at all times. Submit plan on how you will ensure room #2 is maintained clean and odor free.
Type B
Section Cited
CCR
85064(k)
Administrator Qualifications and Duties
(k) Within six months of becoming an administrator, the individual shall receive training on HIV and TB required by Health and Safety Code Section 1562.5. Thereafter, the administrator shall receive updated training every two years.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Administrator did update HIV and TB training. Last training was in 2016. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator agreed to update and complete HIV and TB training by POC date. Submit copy of certificate to CCL by POC 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:Desaree Perera
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 12/06/2023 05:58 PM - It Cannot Be Edited


Created By: Zabel Chochian On 12/06/2023 at 04:05 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: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80076(a)(18)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above. Food observed uncovered in the refrigerator. This poses/posed a potential health and safety risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator stated he will provide in-service training to staff handling food items. Submit copy of in-service conducted with staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 12/06/2023 05:58 PM - It Cannot Be Edited


Created By: Zabel Chochian On 12/06/2023 at 04:41 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: 12/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(c)
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. Missing file for staff #4.
This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/08/2023
Plan of Correction
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Administrator agreed to provide copy of the required records for staff #4 by POC date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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3
4
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: 12/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023


LIC809 (FAS) - (06/04)
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