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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850086
Report Date: 05/19/2023
Date Signed: 05/19/2023 06:08:21 PM

Document Has Been Signed on 05/19/2023 06:08 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:
05/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Joji JunioTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian conducted a case management - deficiencies visit to address deficiencies identified during a complaint investigation regarding complaint number 29-AS-20230518073800. LPA was joined by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Ryan Landseadel.

Between 4:45pm to 5:15 interview was conducted with Ms. Junio. It was revealed that administrator for this facility is her son Lorenzo Banas. However, Mr. Banas has been on vacation since 5/5/2023 and is due back 6/6/2023. Staffing schedule provided to LPA to review shows Mr. Banas on schedule since beginning of 5/2023 to 5/21/2023. This is not accurate. No proof of any acting administrator for this facility since 05/06/2023 - 05/19/2023.

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: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/19/2023
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 05/19/2023 06:08 PM - It Cannot Be Edited


Created By: Zabel Chochian On 05/19/2023 at 05:33 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: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2023
Section Cited
CCR
85064(f)

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(f) When the administrator is absent from the facility there shall be coverage by a designated substitute, who meets the qualifications of Section 80065, who shall be capable of, and responsible and accountable for, management and administration of the facility in compliance with applicable law....
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Licensee/Administrator shall submit proof of appropriate Administrative coverage for the facility. Provide the schedule hours for the administrator for each JJ Residential Care Home. Also provide any updates and changes of administrator for this home and the sister facilities.
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This requirement is not met as evidence by: Based on interview with Ms. Junio and staff schedule review did not show a valid administrator on duty from 5/6/2023 - 5/21/2023.
This poses a potential health, safety or personal rights 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:Desaree Perera
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023


LIC809 (FAS) - (06/04)
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