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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609848
Report Date: 11/18/2021
Date Signed: 11/19/2021 08:35:06 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
11/09/2021 and conducted by Evaluator Teresa Camara
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20211109133011
FACILITY NAME:JJ RESIDENTIAL CARE IIIFACILITY NUMBER:
567609848
ADMINISTRATOR:BANAS, AMELIA/JUNIO, RAMONFACILITY TYPE:
735
ADDRESS:810 GREENBRIAR AVENUETELEPHONE:
(805) 422-8659
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:4CENSUS: 4DATE:
11/18/2021
UNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Amelia BanasTIME COMPLETED:
02:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has inadequate record keeping
Uncleared adults are present in the home
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Teresa Camara conducted an initial complaint investigation visit. LPA was joined by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Freddie Garcia. LPA and QAS met with back-up Administrator Ramon Junio and Administrator Amelia Banas.

LPA and QAS arrived at the facility at 11:23 a.m., conducted a brief facility tour accompanied by staff at 11:27 a.m., interviewed the Administrators starting at 11:34 a.m, and reviewed staff records at 01:05 p.m. All staff scheduled to work at the facility had all appropriate documentation and all had DOJ/FBI background clearances. All back-up staff for the facility also had appropriate documenttion and background clearances on file at the facility.

No deficiencies were observed. Exit interview conducted with Administrator. A copy of the report was emailed to Administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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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