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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850086
Report Date: 07/07/2022
Date Signed: 07/07/2022 04:28:06 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
06/07/2022 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20220607132052
FACILITY NAME:JJ RESIDENTIAL CARE IV, INC.FACILITY NUMBER:
565850086
ADMINISTRATOR:BANAS, AMELIAFACILITY TYPE:
735
ADDRESS:1117 LUNDY DRTELEPHONE:
(805) 404-9120
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:4CENSUS: 3DATE:
07/07/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Lorenzo BanasTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Incidents not being reported by facility administrator to licensing or regional center
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegation. LPA was joined by Tri-Counties Regional Center Quality Assurance Specialists LIz Aced-Arnett. LPA met with Administrator Lorenzo Banas and explained the reason for the visit.

LPA conducted an interview with the Administrator regarding ongoing notes by staff and a prior interview with staff 3 (S3). S3 had documented Resident 1 (R1) had a behavioral episode on 05/17/2022 in which R1 was jumping (while seated) up and down on the bed. S3 was aware this episode caused bruising on R1's buttocks and leg but failed to document the injury. The Administrator failed to report the 05/17/2022 incident and was unaware of the bruising until it was reported to him by R1's family member. The Administrator did not report the 05/17/2022 incident and injury until 06/17/2022, therefore this allegation is deemed Substantiated at this time.
Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (see LIC 9099-D.). Exit interview conducted. A copy of the report and appeal rights were provided via email.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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 3
Control Number 29-AS-20220607132052
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 IV, INC.
FACILITY NUMBER: 565850086
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/15/2022
Section Cited
CCR
80061(b)(1)(E)
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80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing
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Administrator reported the incident on 06/17/2022. Administrator
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agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.

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This requirement was not met as evidenced by:
Administrator failed to report a behavioral incident which resulted in bruising on R1.in a timely manner, which poses a potential health and safety 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.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
06/07/2022 and conducted by Evaluator Teresa Camara
COMPLAINT CONTROL NUMBER: 29-AS-20220607132052

FACILITY NAME:JJ RESIDENTIAL CARE IV, INC.FACILITY NUMBER:
565850086
ADMINISTRATOR:BANAS, AMELIAFACILITY TYPE:
735
ADDRESS:1117 LUNDY DRTELEPHONE:
(805) 404-9120
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:4CENSUS: 3DATE:
07/07/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Lorenzo BanasTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Unexplained bruises on resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Teresa Camara conducted a subsequent complaint investigation visit regarding the above noted allegation. LPA was joined by Tri-Counties Regional Center Quality Assurance Specialists LIz Aced-Arnett. LPA met with Administrator Lorenzo Banas and explained the reason for the visit.

LPA previously conducted staff interviews and reviewed ongoing notes from staff. It was confirmed in staff notes that Resident 1 (R1) had a behavioral incident on 05/17/2022, however staff failed to note later that the behavioral incident resulted in bruising. R1 had been jumping up and down while seated on the edge of the bed. The bed has a metal frame and a soft mattress. At approximately 12:15 p.m. LPA tested the bed and found the staff's explanation of events feasible. The Administrator has orderd a box spring for the bed in an effort to prevent future injuries. LPA found no evidence of lack of supervision or inappropriate actions by staff which caused this bruising. Therefore, this allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted and report emailed to Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3