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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850086
Report Date: 03/25/2024
Date Signed: 03/28/2024 09:42:15 AM

Document Has Been Signed on 03/28/2024 09:42 AM - 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: 4DATE:
03/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Lorenzo BanazTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted an annual required visit today. LPA met with facility staff and explained the reason for this visit. Administrator was contacted and arrived shortly after.
Upon entry a physical plant tour was conducted with staff at approximately 11am. Bedrooms: There are four (4) private bedrooms and two restrooms designated for residents' use. Strong urine odor was coming from client #3's room. All other bedrooms observed clean; all four (4) bedrooms were properly furnished and had sufficient lighting. Bathrooms: There are two (2) bathrooms designated for clients' use. Both bathrooms observed clean and properly supplied. Hot water temperature was 113 degrees Fahrenheit. Cleaning supplies observed locked in the cabinets in the garage. Common Areas: These included the living room and dining area. The common areas appeared clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. Facility does not have a pool or any similar bodies of water at the property. All smoke/carbon monoxide detectors were tested and function properly. The fire extinguisher was located in the kitchen area and appeared functional with record of service date 03/15/2024. Kitchen: The kitchen appeared clean and the appliances and fixtures functional; observed at leasts two (2) day supply of perishable and seven (7) non-perishable food at the facility; properly stored. Knives and cleaning supplies are stored in locked cabinet under the sink. LPA observed sufficient cleaning/disinfecting supplies stored in locked cabinet in the garage.

LPA reviewed client and staff files between 11:30am-1pm. Client files reviewed included an admission agreement, quarterly updates, medical assessments, physician orders for medications and centrally stored medication logs. Client files did not include an updated individual program plan and behavior plan. Administrator stated that he recently followed up with the clients' Service Coordinator and is waiting for the updated IPPs'. Client files did include the Quarterly meeting updates.

Staff files reviewed for regularly scheduled staff at the facility. (Continue to LIC 809C)
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.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 files included current first aid and CPR certifications as well as sufficient training documentation. Staff present during visit are fingerprint cleared and associated to this facility. Number of staff scheduled observed to be sufficient to meet the needs of clients present during todays visit (3:3). Medications observed locked in the storage space near the entrance. Medication records, policy and procedures reviewed with administrator at approximately 1:30pm-2:15pm. Medication audit revealed that administrator is not accurately recording medications, and missing expiration dates, fill and start dates for R1's and R3's medications. Also Administrator did not have a Centrally Stored Record of R4's medication. Administrator did not have a PRN authorization letter on file for R1 and R3.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D):
Exit interview conducted. Copy of report and appeal rights reviewed and issued.
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
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 03/28/2024 09:42 AM - It Cannot Be Edited


Created By: Zabel Chochian On 03/25/2024 at 03:38 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: 03/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(k)(7)(A)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: (A) The name of the client for whom prescribed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on medication record review, the licensee did not comply with the section cited above in three (3) out of four (4) residents medication records reviewed revealed that administrator did not have a centrally stored record log of R4's medications; did not record all of R1's and R3's medications on the required log (centrally stored medication record) accurately (missing expiration and start dates.. This poses a potential health, and safety risk to persons in care.
POC Due Date: 04/01/2024
Plan of Correction
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Administrator agreed to review all residents medication and complete new or update centrally stored record log to record all current residents' medication on this log. Submit self-certification letter once all residents medications are reviewed and recorded according to Titile 22. Submit copy of the self certification letter and central stored record for R1, R3, R4 by POC due date 4/1/2024.
Type B
Section Cited
CCR
80077.4(b)
Care for Clients with Incontinence
(b) If a licensee accepts or retains a client who has bowel and/or bladder incontinence, the licensee is responsible for all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,interview and record review, the licensee did not comply with the section cited above. R3's room smelled of strong urine odor during the inspection. Staff reported that they are unable to manage R3 since resident urinates and defecates in room on the floor every day. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 04/01/2024
Plan of Correction
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Administrator agreed to develope and maint an updated incontinent care plan and inservice staff on deep cleaning R3's room. Submit copy of the plan and inservice conducted with staff.
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: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 03/28/2024 09:42 AM - It Cannot Be Edited


Created By: Zabel Chochian On 03/25/2024 at 03:38 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: 03/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Last record of emergency drill was conducted in 6/2023. This poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 04/01/2024
Plan of Correction
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Administrator agreed to coordinate and conduct the emergency drill with all staff. Submit record of emergency drill conducted with all staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024


LIC809 (FAS) - (06/04)
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