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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609848
Report Date: 08/20/2021
Date Signed: 08/20/2021 04:36:09 PM

Document Has Been Signed on 08/20/2021 04:36 PM - 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:
08/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Amelia BanasTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management-Deficiencies inspection visit at the facility today due to deficiencies observed during the investigation of complaint control # 29-AS-20201124152226. Tri-Counties Regional Center Quality Assurance Specialist (QAS) Freddie Garcia was also present during the visit.

During today’s visit, the LPA and QAS spoke with the Administrator about client #1 (C1), and inquired about C1’s care plan as it relates to C1's recent episodes of aggression. Per the incident from 5/12/2021, C1 had a behavioral episode where C1 threw a large object at both the staff and the property. During today's visit, the LPA and QAS observed large items throughout the surrounding area that can pose a health and safety risk.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2021
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 08/20/2021 04:36 PM - It Cannot Be Edited


Created By: Ashley Smith On 08/20/2021 at 01:47 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 III
FACILITY NUMBER: 567609848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2021
Section Cited
CCR
80087(a)

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80087(a) Buildings and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidenced by:
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The Administrator has agreed to do the following:
1. Remove all other potentially dangerous items from the facility. Walk around the perimeter and ensure it is clean and orderly.

This has been completed and is cleared.
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Based on observation and interview, the facility did not comply with the section cited above, as the facility failed to keep dangerous items inaccessible to C1, 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:Ashley Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021


LIC809 (FAS) - (06/04)
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