567609848-9-13-2021-29-AS-JAPL-C6V39R-20210914180332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609848
Report Date: 09/13/2021
Date Signed: 09/13/2021 09:32:45 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/24/2020 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20201124152226

FACILITY NAME:	JJ RESIDENTIAL CARE III		FACILITY NUMBER:	567609848
ADMINISTRATOR:	BANAS, AMELIA/JUNIO, RAMON		FACILITY TYPE:	735
ADDRESS:	810 GREENBRIAR AVENUE		TELEPHONE:	(818) 585-9070
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	4	CENSUS: 4	DATE:	09/13/2021
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Lorenzo Banas		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Facility staff did not properly supervise resident.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit at 9:10 a.m. The LPA met with Administrator Lorenzo Banas and explained the reason for the visit.

During a previous virtual visit conducted on 12/03/2020, LPA Aja Richardson interviewed Administrator Ramon Junio at 4:45 p.m. and requested documents. During an in-person visit conducted on 7/28/2021, LPA Smith toured the facility at 10:20 a.m., reviewed and requested documents, and interviewed staff at 10:56 a.m., 11:00 a.m., 11:25 a.m., 11:31 a.m., and 12:00 p.m., and interview a client at 12:05 p.m. During a visit conducted on 8/20/2021, the LPA toured the facility at 12:10 p.m., reviewed documents, and interviewed staff at 12:34 p.m. and a client at 12:28 p.m.

CONT 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20201124152226

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III	FACILITY NUMBER: 567609848
	VISIT DATE: 09/13/2021

NARRATIVE

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Regarding the allegation, it was alleged that staff failed to supervise Client #1 (C1), as C1 allegedly left Oxnard Beach and was found at the Ventura Harbor, which is approximately 5 miles from where C1 was supposed to be. Interviews and record review revealed that this facility had an outing at Oxnard Beach on 9/24/2020. C1 was observed to be walking behind two staff that were walking to the facility car. Suddenly and without incident, C1 began to walk away from the group. interviews confirmed that they saw C1 leaving the group and called over to C1, but C1 did not listen and continued to walk away. Staff interviews confirmed that staff observed C1 walking away from the group and staff began walking towards C1, yet C1 began to run. Staff stated that they had C1 in eyesight as they were running after C1, but as C1 began to run, C1 ran out of sight for several minutes. Staff nor clients stated that there was not an issue or event that prompted C1 to leave the group and claimed that it was unexpected. Staff stated that as they lost eyesight of C1, they asked nearby persons of C1’s whereabouts, whom confirmed the direction that C1 ran towards. During that time, law enforcement was contacted. C1 was found by the Oxnard Police and was returned to Oxnard State Beach Park.

Records review and interviews confirmed that at the time of the incident, C1 did not have an assigned 1:1 staff person and did not have a history of elopement. Staff were alerted once C1 distanced themselves from the group, followed C1, and alerted law enforcement for additional support. As a result of the incident, the Administrator requested supplemental support hours for three (3) hours a day to ensure that C1 remains safe and supported at all times. In addition, C1 was supplied with an ID necklace in case of emergencies.

Based on the investigation, there is insufficient evidence to support the claim that facility staff did not properly supervise resident. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC9099 (FAS) - (06/04)

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