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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802466
Report Date: 03/16/2023
Date Signed: 05/26/2023 09:03:04 AM

Document Has Been Signed on 05/26/2023 09:03 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
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:
03/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Lorenzo BanasTIME COMPLETED:
03:15 PM
NARRATIVE
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In conjunction to complaint visit (# 29-AS-20230307111341) a Case Management-Deficiencies report is being generated to document deficiency observed during the complaint visit. During records review it was revealed that the staff files are not maintained accordingly with all required records such as training records; health screening; first aide/CPR records etc. Administrator had to gather records from other sister facilities to present and therefore visit to much longer than usual.

Pursuant to Title 22 Division 6 Chapter 1 of the CA Code of Regulations, the following deficiency were cited (refer to LIC 809-D). Exit interview completed, copy of report and appeal rights provided.
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/26/2023 09:03 AM - It Cannot Be Edited


Created By: Zabel Chochian On 03/16/2023 at 01:49 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: 03/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/23/2023
Section Cited
CCR
82066(a)

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Personnel Records: The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information:
This requirement was not met as evidenced by:
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Administrator agreed to review all staff files and ensure all required records are maintained and up to date accordingly. Submit self-certification letter when all staff files are reviewed and updated with required records. Plan of correction due buy 3/23/23.
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Based on records review and interview with administrator - seven out of seven staff records reviewed lacked required records such as TB clearance; training records; first aide/cpr etc.
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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: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


LIC809 (FAS) - (06/04)
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