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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850086
Report Date: 06/07/2022
Date Signed: 06/13/2022 10:34:46 AM

Document Has Been Signed on 06/13/2022 10:34 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: 3DATE:
06/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Lorenzo BanasTIME COMPLETED:
04:23 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management-deficiencies visit to address deficiencies identified during a complaint investigation regarding complaint number 29-AS-20220607132052. LPA was joined by Tri-Counties Regional Center Quality Assurance Specialists LIz Aced-Arnett and Ryan Landseadel. LPA met with Administrator Lorenzo Banas and explained the reason for the visit.

Staff 1 (S1) was confirmed through interviews with administrator and staff to be a regularly scheduled staff at the facility. S1 has a criminal background clearance but is not associated to the facility.

A $500 immediate civil penalty is assessed today. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D).

Exit interview conducted, civil penalty issued, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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 06/13/2022 10:34 AM - It Cannot Be Edited


Created By: Teresa Camara On 06/07/2022 at 03:50 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: 06/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2022
Section Cited
CCR
80019(e)(2)

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Criminal Record Clearance. All individuals subject to a criminal record review shall, prior to working, residing or volunteering in a licensed facility, request a transfer of a criminal record clearance.

80054(b)(1) Penalties. If any individual required to be fingerprinted has not
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Administrator will ensure S1 is associated to the facility before allowing S1 to return to the facility. Administrator will provide LPA with documentation of association of S1 by 06/10/2022.
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obtained a California clearance or a criminal record exemption, or requested a transfer of a criminal record clearance, or requested and been approved for a transfer of an exemption, prior to working, residing or volunteering in the facility, an immediate penalty of $100 per cited violation per day for a maximum of five (5) days shall be assessed.
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Based on interviews with the administrator and staff, S1 has been working at the facility since approximately April of 2022 and is not associated to the facility, which poses an immediate health and safety risk to clients in care.

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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:Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022


LIC809 (FAS) - (06/04)
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