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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609848
Report Date: 08/02/2023
Date Signed: 08/02/2023 07:11:57 PM

Document Has Been Signed on 08/02/2023 07:11 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:
08/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:41 PM
MET WITH:Ramon JunioTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian a Case Management visit to the facility regarding an unusual incident reported to the Department on 05/16/2023. The LPA met with one of the Administrators - Mr. Ramon Junio. Reason for visit was explained.

The facility self reported an incident, which described that on 5/08/2023, Client #1 (C1) and Client #2 (C2) went to C1's room to play video games and closed the door because they wanted privacy. Staff #1(S1) reported hearing C1 whining and went to see what is going on. S1 knocked and open C1's door; C1 reported that they are just playing around. S1 observed C1 playing video game and C2 siting on the bed. S1 asked the clients to leave the door open and clients agreed. No unusual incident was reported at the time. The following day on 5/9/2023, S1 asked C1 to open up and say what happened while C1 and C2 were playing video games and C1 opened up and reported that C2 was playing rough.

On 5/16/2023, a follow-up incident report was sent to LPA that there may have been non-consensual sexual behavior between C1 and C2. C1 was taken to the Simi Valley Adventist hospital by staff for an evaluation but C1 refused to be evaluated. Law Enforcement was contacted and police arrived at the hospital. C1 did not report any unusual incident happening on 5/8/2023.

During todays visit LPA reviewed records from 3:45pm-4:15pm; and conducted Interview with three (3) out of the four (4) clients and S1 from 4:30pm-5:30pm. Clients reported feeling safe in the home; no report of any mistreatment by clients or staff. S1 did not observe any unusual incident between the clients at the time of incident on 5/08/2023. Based on the interviews conducted there is no evidence that non-consensual sexual behavior occurred between C1 and C2 at this time. Although the investigation did not reveal any evidence of non-consensual sexual behavior between C1 and C2, the facility is being cited for not meeting reporting requirements. Administrator had knowledge of the alleged abuse on 5/9/2023 and did not report finding within 24 hours to the department until 5/16/2023. The following deficiencies were cited pursuant to Title 22 of the CA Code of Regulations. Exit interview conducted. A copy of the report, and appeal rights provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/02/2023 07:11 PM - It Cannot Be Edited


Created By: Zabel Chochian On 08/02/2023 at 05:21 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: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2023
Section Cited
HSC
80064(a)(3)

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80064 Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation.
This requirement was not met as evidence by:
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The administrator shall obtain training from an outside vendor regarding Mandated Reporting and CCLD reporting requirements in accordance with 80061. Proof shall be submitted to CCLD by 8/16/2023.
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Based on records review and interview with Administrator and staff it was revealed that an alleged abuse report was not submitted timely when information was discovered on 5/9/2023. Incident and SOC341 was submitted to CCL on 5/16/2023.
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Type B
08/16/2023
Section Cited
CCR80061(d)

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Reporting Requirements:(d)Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within 24 hrs....
This requirement is not met as evidence by:
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The administrator shall obtain training from an outside vendor regarding Mandated Reporting and CCLD reporting requirements in accordance with 80061. Proof shall be submitted to CCLD by 8/16/2023.
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Based on records review and interview with Administrator it was revealed that incident alleging abuse was not reported accordingly as required. Alleged incident of abuse was discovered on 5/9/2023 and was reported to CCLD on 5/16/2023.
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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:Desaree Perera
LICENSING EVALUATOR NAME:Zabel Chochian
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023


LIC809 (FAS) - (06/04)
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