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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850086
Report Date: 02/25/2025
Date Signed: 02/25/2025 02:13:08 PM

Document Has Been Signed on 02/25/2025 02:13 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: 4DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Pamela BanasTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with Staff and explained the reason for the visit. Assistant Administrator Pamela Banas arrived shortly after. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

LPA inspected the kitchen/food service area at approx. 09:50 a.m. The LPA observed one client sitting in the living room and another client sitting at the dining table.  Knives and sharp objects are stored in a locked cabinet underneath the sink. No cleaning supplies were observed stored in the kitchen. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time.

At the time of the visit, the common area furniture's were observed to be in good condition. LPA observed medication, first aid kit, facility records stored in the hallways closet inaccessible to residents in care. LPA observed emergency food supply, supplies for emergency and PPE stored in hallways closet near the entry way. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and last serviced 03/15/2024.

All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage observed inaccessible to clients in care. LPA observed garage to store an additional fridge to store extra perishable food that staff bring in. LPA also observed laundry area, along with additional furniture and medical equipment for facility use. Cleaning supplies were observed inaccessible in a cabinet in the garage. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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: 02/25/2025
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Records review began at approx. 10:20am, four (4) client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Five (5) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. At approx 10:45 a.m. LPA observed staff sitting and talking with a client in the backyard.  All files were observed to be in order at this time. Last emergency disaster drill was conducted in December 2024

Medications review began at approx. 01:20 p.m. All medications including PRNs were labeled, stored and inaccessible to residents in care. Medications were observed to be administered as prescribed at this time.
 
At approx 2pm, LPA discussed infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE), and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, and a copy of the emergency disaster plan. Interviews were conducted during the visit.
 
Exit interview conducted. A copy of the report were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC809 (FAS) - (06/04)
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