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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850086
Report Date: 07/07/2022
Date Signed: 07/07/2022 04:24:55 PM

Document Has Been Signed on 07/07/2022 04:24 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 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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Lorenzo BanasTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management - deficiencies visit to address deficiencies identified during a complaint investigation regarding complaint number 29-AS-20220607132052. LPA was joined by Tri-Counties Regional Center Quality Assurance Specialist (QAS) LIz Aced-Arnett. LPA met with Administrator Lorenzo Banas and explained the reason for the visit.

During today's visit, QAS arrived earlier in the morning and prior to LPA's arrival found staff 4 (S4) had been sleeping in the living room. During LPA's previous interviews with other staff it was stated staff sleep in the living room.

In addition, QAS observed the following deficiencies prior to LPA's arrival and provided photos of the following: medication closet keys (two sets) left in unlocked drawers in the kitchen and paint and gasoline on an open shelf in the garage. Staff secured the gasoline and paint in a locked cabinet. Staff secured the medication closet keys.

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (see LIC 809-D).

Exit interview conducted, appeal rights discussed, and a copy of this report issued.
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.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 07/07/2022 04:24 PM - It Cannot Be Edited


Created By: Teresa Camara On 07/07/2022 at 01:14 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 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 A
07/07/2022
Section Cited
CCR
80087(g)(1)

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80087(g)(1) Buildings and Grounds. Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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Administrator instructed staff to keep toxic substances in a locked cabinet locked and will hold training with all staff regarding keeping dangerous items inaccessible to residents. Evidence of training will be provided to CCL on or before 07/15/2022.
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This requirement was not met as evidenced by:
Gasoline and paint were observed on an open shelf in the garage, which poses an immediate health and safety risk to persons in care.
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Type A
07/07/2022
Section Cited
CCR80075(k)(1)

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80075 (k)(1) Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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Administrator instructed staff to keep the keys with them at all times and will hold training with all staff regarding keeping medications inaccessible to residents. Evidence of training will be provided to CCL on or before 07/15/2022.
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This requirement was not met as evidenced by:
Two sets of keys for the medication closet were left in unlocked drawers in the kitchen, which poses an immediate 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/07/2022 04:24 PM - It Cannot Be Edited


Created By: Teresa Camara On 07/07/2022 at 01:58 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 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
85087(a)(3)

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85087(a)(3) Buildings and Grounds (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.
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Administrator notified staff not to use the living room as sleeping quarters. Administrator will conduct training with staff regarding appropriate places to take breaks at the facility and provide evidence of training to CCL by 07/15/2022.
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This requirement was not met as evidenced by:
Staff indicated they use the living room as sleeping quarters at night. Staff was observed sleeping in the living room, 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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