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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850086
Report Date: 09/07/2023
Date Signed: 09/07/2023 05:20:00 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
08/28/2023 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20230828170543
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: 4DATE:
09/07/2023
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Joji Junio, Assistant AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff sleep in common areas
Staff schedule not accurate/posted
Required staff records not on file/updated
Required resident records not on file/updated
Administrator not managing the facility in compliance with applicable laws and regulations
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced complaint visit regarding above allegations. Upon arrival LPA met with staff Nicholas K. Staff contacted assistant administrator Joji Junio who arrived to the facility shortly after. Entrance interview was conducted and the reason for todays visit was discussed.

Per the Corrective Action Plan (CAP) issued by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist Ryan Landseadel and Quality Assurance Manager Freddie Garcia, deficiencies were observed on visits that took place on 5/13/2023, 6/15/2023 and 7/18/2023. During todays visit LPA conducted a physical plant tour with staff at approximately 12pm. Interview conducted with staff from 12:30pm-1:15pm; Staff files reviewed at approximately 1:30pm. Staff interviews revealed that staff did sleep in the common areas prior to TCRC visit conducted on 7/18/2023.
Regarding allegation "staff schedule not accurate/posted; Current staffing schedule for this week was not available/posted during todays visit for review; Regarding alllegation "Required staffing records not on file" -
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
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 5
Control Number 29-AS-20230828170543
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
VISIT DATE: 09/07/2023
NARRATIVE
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Staff #1 did not have a current first aid/cpr certificate on file during today's review. TCRC review conducted on 7/18/2023 observed several missing records for staff. Regarding allegation "Administrator not managing the facility in compliance with applicable laws and regulation" - Administrator Lorenzo Banas did not complying with the corrective action plan issued by TCRC on 6/15/2023. Administrator Lorenzo Banas is not operating according to the approved facility program design - resident progress reports and behavioral plans not updated.

Based on the information gathered allegations are deemed substantiated at this time.

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

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20230828170543
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: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/08/2023
Section Cited
CCR
85087(a)(3)
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(a) In addition to Section 80087, bedrooms must meet, at a minimum, the following requirements:(3)No room commonly used for other purposes shall be used as a bedroom for any person.
This requirement is not met as evidence by:
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Mrs. Junio stated that moving forward staff will not be allowed to sleep at the facility.
Submit written letter to self-certify above statement by 09/08/2023.
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Based on interview with staff and review of TCRC investigation report it was revealed that staff did sleep in common areas of the facility. This poses an immediate personal rights, health and safety risk to clients in care.
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Type B
09/11/2023
Section Cited
CCR
8066(c)
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(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 evidence by:
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Mrs. Junio agreed to prepare and submit a staff schedule for the current week and past week from 8/28-9/08/2023. Also submit self certification letter as to what action will be taken to ensure compliance with developing and maintaining accurate staffing schedule. Submit by 9/11/2023.
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Based on observation during today's visit and interview with staff and Mrs. Junio there was no current accurate staff schedule for the last and current week. This poses a potiential persona, health and safety risk to clients 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: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20230828170543
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: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/11/2023
Section Cited
CCR
80075
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(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. This requirement is not met as evidence by:
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Mrs. Junio agreed to obtain current first aid certificate for staff Anna N. Submit copy of current first aid by 9/11/2023.
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Based on staff records reviewed one (1) out of five (5) records reviewed lacked current first aid training certificate on file.
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Type B
09/14/2023
Section Cited
CCR
85068.3
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(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning. This requirement is not met as
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Mrs. Junio agreed to review all residents progress reports and behavioral plans and ensure it is up to date. Submit self-certification letter once completed by 9/14/2023.
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evidence by: Based on TCRC annual review and resident records reviewed during todays visit Administrator did not keep accurate quarterly progress reports and behavioral plans for residents 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: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230828170543
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: 09/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2023
Section Cited
CCR
85064(e)
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(e) The administrator shall be on the premises the number of hours necessary to manage and administer the facility in compliance with applicable law and regulation.
This requirement is not met as evidence by:
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Mrs. Junio will discuss with Mr. Banas and submit a plan to ensure administrator coverage is met to manage and administer facility in compliance with applicable laws and requlations.
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Based on the TCRC investigation
and todays substantiated findings - Administrator did not comply with this section.
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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: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5