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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802466
Report Date: 12/10/2024
Date Signed: 12/10/2024 04:46:16 PM

Document Has Been Signed on 12/10/2024 04:46 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:JJ RESIDENTIAL CARE IIFACILITY NUMBER:
565802466
ADMINISTRATOR/
DIRECTOR:		BANAS, LORENZOFACILITY TYPE:
735
ADDRESS:1542 DEANNA AVETELEPHONE:
(805) 791-3260
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 4DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:34 PM
MET WITH:Lorenzo BanasTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 01:34 PM. LPA met with facility staff who contacted facility Administrator Lorenzo Banas via telephone call. Facility Administrator arrived to the facility at approximately 02:10 PM Entrance interview conducted and the reason for the visit was explained.

Beginning at 01:35 PM, the LPA, along with the facility staff 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:

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 under sink 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 03/15/2024.

GARAGE: LPA observed the garage to contain one (1) extra refrigerator, adequate emergency food and water supplies, and a locked storage cabinet. The cabinet was observed to contain cleaning supplies and chemicals.

BEDROOMS: There are five (5) bedrooms in the facility; four (4) are designated for resident use and one (1) is designated as a staff room. All four (4) resident bedrooms are private rooms. LPA and the facility staff member 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. Bedroom number four (4) contains a direct exit to the outside of the facility.
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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Document Has Been Signed on 12/10/2024 04:46 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/10/2024 at 04:22 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

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 one fire alarm was observed to not function properly during the test of the facility's fire alarms which poses an immediate safety risk to persons in care.
POC Due Date: 12/11/2024
Plan of Correction
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Licensee will submit proof of fire alarm functioning properly 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)
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Document Has Been Signed on 12/10/2024 04:46 PM - It Cannot Be Edited


Created By: Trevor Byrne On 12/10/2024 at 04:22 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: 12/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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's kives are stored in an under-sink cabinet in the kitchen alongside soaps, bleach, and other cleaning chemicals 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.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

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 aboveas the facility's last emergency disaster drill was conducted on 06/21/2024 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 conduct an emergency disaster drill and will submit proof of completion 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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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 II
FACILITY NUMBER: 565802466
VISIT DATE: 12/10/2024
NARRATIVE
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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 both bathrooms to contain locked under sink cabinets. The cabinets contained personal grooming supplies. The water temperature was measured in all bathrooms between 108.1 degrees Fahrenheit and 111.6 degrees Fahrenheit which is within the range required by regulation.

COMMON AREAS: This includes the living room, dining room, laundry 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 three (3) properly secured cabinets. One secured cabinet contained resident medications, first aid supplies, and activity supplies. The other secured cabinets contained clean linens and cleaning chemicals.



OUTDOOR SPACE: The facility has one (1) emergency exit gate, LPA observed clear passageways for emergency exit use. The facility has adequate shaded outdoor seating for resident use.

RECORD REVIEW: Client record review began at 02:18 PM. Client Records were reviewed for documents including, but not limited to: health screening, TB test, resident physician's report, needs and service appraisal, consent forms, and personal rights. Four (4) resident files were reviewed. One (1) resident file was observed to be missing identification and emergency information. Staff file review began at 03:16 PM. Staff files were reviewed for documents including, but not limited to: staff training records, fingerprint clearance, TB tests and criminal record clearance. Six (6) staff files were reviewed. All staff files contained the required documents and trainings.

MEDICATION REVIEW / CASH RESOURCE REVIEW: Medication review began at 02:47 PM. Medications for four (4) of four (4) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Cash resources were reviewed for three (3) of four (4) residents. All cash resources were documented appropriately and accurately and were accompanied by corresponding purchase receipts. No deficiencies were observed during cash resource review.
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
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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 II
FACILITY NUMBER: 565802466
VISIT DATE: 12/10/2024
NARRATIVE
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are to be conducted quarterly; the facility’s last emergency disaster drill was conducted on 06/21/2024 which is outside of the required timeframe. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator.

INTERVIEWS: LPA interviewed one (1) resident and two (2) staff members. The resident interviewed stated that the staff treat them well. The resident had no concerns with the facility. Both staff interviewed understood their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

Smoke detectors and carbon monoxide detectors were tested at 11:48 AM one (1) fire alarm was observed to not function properly during the test, all other alarms and the facility’s fire door were functional at the time of the visit. LPA informed the Administrator that this is a violation of the fire clearance that was approved for this facility which poses an immediate health and safety risk to residents in care. This is a zero-tolerance violation and an immediate civil penalty of $500 is being assessed.

During today’s visit LPA obtained a copy of the facility’s LIC 500 and resident roster. The facility was unable to provide a copy of their updated liability insurance or surety bond at the time of the inspection.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited, and civil penalty issued. (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)
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