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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850086
Report Date: 03/25/2024
Date Signed: 03/28/2024 09:43:36 AM

Unsubstantiated


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
05/18/2023 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20230518073800
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:
03/25/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lorenzo BanasTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff mishandled resident which resulted in bruising
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to the facility. The purpose of the visit is to deliver the investigation findings for the above allegation. LPA met with Lorenzo Banas and investigation finding was discussed.

On 05/18/2023, the Department received a complaint alleging that Client #1’s (C1) arm was bruised as a result of staff mishandling C1. Following is a summary of the investigation finding:
On 5/19/2023, from approximately 1:45 p.m. to 4:45 p.m., LPA conducted the initial complaint visit. LPA was accompanied by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Ryan Landseadel. Clients record review was conducted at approximately 1:50 p.m. Three (3) out of three (3) staff interviewed denied the allegation. Staff reported that they have not mistreated or mishandled any client. C1 was interviewed, however due to client having limited verbal skills C1 was unable to answer the questions accordingly. Staff interviews confirmed that C1 does have self-injuries behavior and may have caused the bruising. (Continue to LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
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 2
Control Number 29-AS-20230518073800
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: 03/25/2024
NARRATIVE
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Staff stated that C1’s skin is very fair and sensitive and therefore bruises easily. According to the staff it is unknown how C1 sustained a bruise on the arm. C1’s parent was interviewed and expressed that they like the staff and feel safe leaving C1 at the facility. C1’s parent also stated that it is unknown how C1 sustained the bruise on the arm.

Based on the information obtained above, there is insufficient evidence to support the allegation that C1’s arm bruising was caused by facility staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of “Staff caused bruising to client’s arm” is deemed UNSUBSTANTIATED at this time.
Exit interview conducted. A copy of the report was emailed.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2