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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850086
Report Date: 05/23/2024
Date Signed: 05/23/2024 05:43:41 PM

Document Has Been Signed on 05/23/2024 05:43 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/
DIRECTOR:		BANAS, AMELIAFACILITY TYPE:
735
ADDRESS:1117 LUNDY DRTELEPHONE:
(805) 404-9120
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: DATE:
05/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Lorenzo BanasTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo along with Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Ryan Landseadel and Quality Assurance Manager (QAM) Freddie Garcia conducted an unannounced Case Management - Incident visit at the facility today due to a Special Incident Report (SIR) that was sent to TCRC. Upon arrival, there were four (4) staff and four (4) clients present. The Administrator, Lorenzo Banas arrived at 3:40 p.m. Entrance interview conducted.

The purpose of today's visit is to follow up on a Special Incident Report (SIR) pertaining to facility staff using physical intervention on Client #1 (C1). During today’s visit, a file review and medication review were conducted, along with staff interviews.

Exit interview conducted. No citations issued at this time. Report was reviewed and a copy was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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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