567609848-9-9-2022-29-AS-TCAA-CJ4NBL-20220909101918

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609848
Report Date: 09/08/2022
Date Signed: 09/09/2022 10:19:48 AM

Document Has Been Signed on 09/09/2022 10:19 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 III		FACILITY NUMBER:	567609848
ADMINISTRATOR:	BANAS, AMELIA/JUNIO, RAMON		FACILITY TYPE:	735
ADDRESS:	810 GREENBRIAR AVENUE		TELEPHONE:	(805) 422-8659
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 4		CENSUS: 4	DATE:	09/08/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:56 AM
MET WITH:	Ramon Junio		TIME COMPLETED:	12:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Teresa Camara arrived at 9:56 a.m. for an unannounced Case Management visit to the facility to issue findings for an incident reported to the Department on 5/12/2021. The investigation was completed by LPA Ashley Smith, alongside Tri-Counties Regional Center Manager Freddie Garcia. The LPA met with administrator Ramon Junio and explained the reason for the visit. The facility self-reported an incident on 5/12/2021, which described that on 5/11/2021, Client #1 (C1) had a behavioral episode, which led to staff allegedly performing a hold on C1 until the police arrived. During the initial visit on 7/13/2021, documents were reviewed, and the LPA interviewed staff at 1:10 p.m., 2:07 p.m., 2:36 p.m., and 3:20 p.m.; and, interviewed C1 at 2:49 p.m. Additional staff interviews took place on 8/20/2021 at 2:11 p.m., and on 9/28/2021 at 1:10 p.m. and 1:41 p.m. A police report pertaining to the case was subpoenaed and reviewed, and an interview with the responding officer took place on 8/5/2021 at 10:25 a.m. Body camera footage pertaining to the 5/11/2021 incident was also subpoenaed and obtained. Interviews revealed that during the incident that took place on 5/11/2021, C1 became physically and verbally upset, began destroying property and threw a large rock at Staff #1 (S1). As a result of C1’s escalating behaviors, S1 used a single-person physical intervention to restrain C1. Interviews and reviewed footage noted that C1 was held in this position for approximately eight (8) minutes without additional staff assistance. The police arrived, and additional interviews confirmed that upon their arrival, the responding officer witnessed S1 on top of C1, holding C1 to the ground. S1 then released C1, who was then transferred to the hospital for a 5150 hold. (continued on 809-C)

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/08/2022

NARRATIVE

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The investigation revealed that S1 utilized a technique from a crisis intervention training that they received while working in another home. The home’s program design indicates that staff would utilize Crisis Prevention Intervention (CPI), or other Regional Center approved training. Whereas CPI training indicates that a two-person restraint for adults is safer and a preferred method whenever possible, S1 utilized a one-person method. Interviews, and a review of body-camera footage confirmed that during the hold, Staff #2 (S2) was witnessed standing close by yet did not assist S1 with implementing an appropriate two-person hold. As a result of the incident, the facility transitioned to utilizing Professional Assault Crisis Training (Pro-Act), which is a regional center approved crisis intervention training program.

Based on the information obtained, S1 utilized a single-person intervention method to restrain C1 for approximately eight (8) minutes. The utilized method was not from an approved crisis intervention training, and an approved two-person restraint should have been utilized, as S2 was in close proximity of C1 and S1.

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

Exit interview conducted. A copy of the report, and appeal rights, were provided.

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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/09/2022 10:19 AM - It Cannot Be Edited

Created By: Teresa Camara On 09/08/2022 at 11:15 AM

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: 09/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/08/2022 Section Cited CCR 80072(a)(3)	1 2 3 4 5 6 7	80072(a)(3)Personal Rights. Each client shall have personal rights which include…: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to…	1 2 3 4 5 6 7	The Administrator agreed to do the following: All staff completed Pro-Act training certification. The Department received the certificates of completion for all staff on 10/12/2021. Plan of Correction met.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview and video footage, the licensee did not comply with the section cited above, as S1 utilized an improper hold on C1, which poses an immediate health and safety risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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:

Teresa Camara

LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022

LIC809 (FAS) - (06/04)

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