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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609848
Report Date: 09/20/2023
Date Signed: 09/29/2023 11:59:40 AM

Document Has Been Signed on 09/29/2023 11:59 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: 3DATE:
09/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Amelia BanasTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with staff. Administrator was contacted and arrived to facility shortly after LPA. Reason for visit was stated.

The LPA toured the physical plant areas inside and outside with staff at approximately 2pm.

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.

RESTROOMS: Restrooms observed clean and sanitary and in operating condition. Hot water temperature measured at 118.6 in the restroom used by clients.

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 in the living room.

The backyard has a covered outdoor area equipped with furniture for resident use. There is a self-latching gate on the side of the facility. There is a gated pool in the backyard, which was locked. The laundry area is in the backyard and the detergents kept inaccessible.

Staff and client files reviewed from 2:30pm-3:30pm. All required forms and training observed on file for staff. Client files have current needs and serves plan; physician report, admission agreement and IPP's. Medication are kept locked in the hallway closet. At approximately 3:30pm, client medication procedures, storage and administration logs observed. Medications observed stored locked and inaccessible in the hallway closet. Medication are dispensed according to physician orders. PRN authorization letters observed on file. No deficiencies observed during todays visit. Exit interview conducted copy of report provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2023
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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