565850086-2-27-2023-29-AS-ZCHN-CPG3FX-20230227171329

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850086
Report Date: 02/27/2023
Date Signed: 02/27/2023 05:14:19 PM

Document Has Been Signed on 02/27/2023 05:14 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, AMELIA		FACILITY TYPE:	735
ADDRESS:	1117 LUNDY DR		TELEPHONE:	(805) 404-9120
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 4		CENSUS: 3	DATE:	02/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:26 PM
MET WITH:	Lorenzo Banas		TIME COMPLETED:	05:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. INFECTION CONTROL: During today’s visit, the LPA spoke with the Co-Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. All facility staff were observed with out a mask upon arrival. LPA reminded staff about the mask requirement then all staff (3) put on their mask.

The LPA observed a supply of Personal Protection Equipment (PPE). The PPE supply at the facility is not a 30 day supply. Mr. Banas stated that the bulk of the PPE is kept at the sister facility. LPA asked that Mr. Banas to transfer and maintain the 30 day supply of PPE at the facility. If needed Mr. Banas stated they are able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

A toured of the physical plant areas inside and outside was conducted to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher appeared to be fully charged. Knives and cleaning supplies are stored in a locked cabinet under the sink. Kitchen appliances appeared to be in operable condition. Perishable and non-perishable food observed sufficient. The bedrooms for clients were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Restrooms observed clean, sanitary and in operating condition. Restrooms had sufficient hand soap and paper towels and appropriate hand washing signs. Living room and dining room furniture was observed to be in good condition. The LPA observed the required postings throughout the facility. The backyard patio is equipped with furniture for clients' use. Medications are stored in a locked closet in the hallway.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (LIC809-D).
Exit interview conducted, copy of this report and appeal rights provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

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 02/27/2023 05:14 PM - It Cannot Be Edited

Created By: Zabel Chochian On 02/27/2023 at 05:01 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: 02/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80072(a)(2)

Personal Rights

(a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 3 out of 3 staff observed without face mask upon arrival to the faclity. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2023
	Plan of Correction
1 2 3 4	Mr. Banas stated he will have an in-service with staff regarding face mask requirements. Submit copy of in-service to LPA by 2/28/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 02/27/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023

LIC809 (FAS) - (06/04)

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