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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609848
Report Date: 09/08/2022
Date Signed: 09/09/2022 10:23:57 AM

Document Has Been Signed on 09/09/2022 10:23 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 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:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH:Ramon JunioTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 9:56 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Co-Administrator Ramon Junio and explained the reason for the visit.

The 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. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher appeared fully charged.

KITCHEN: Knives and cleaning supplies are stored in a locked cabinet under the sink. Kitchen appliances appeared to be in operable condition. Perishable and non-perishable food appeared sufficient.

BEDROOMS: The LPA observed four single-occupancy client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Medications are stored in a locked cabinet in the hallway. RESTROOMS: Restrooms are clean and sanitary and in operating condition.

COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings throughout the facility. The backyard patio is equipped with furniture for clients' use and the pool is fenced with a locked gate.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. Facility staff were not wearing masks and were instructed they must wear them at all times in the facility. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

No deficiencies observed. Exit interview conducted. Report emailed to Administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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