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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609848
Report Date: 06/19/2026
Date Signed: 06/19/2026 10:32:03 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2025 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20251027152644
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:
06/19/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amelia BanasTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff falsify documentation regarding resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver final findings of the allegations listed above. Upon arrival LPA met staff and explained the reason for the visit. Administrator Amelia Banas arrived shortly after.

On 10/30/2025, LPA conducted an initial 10-day complaint visit to investigate the allegations listed above. At approximately 09:30 a.m. LPA conducted physical plant tour, interviewed staff, residents, reviewed medication and reviewed and obtained copies of pertinent documentation relevant to the investigation. On 03/20/2026, LPA conducted a subsequent complaint visit to continue allegations listed above. At approx. 10:30 a.m. LPA conducted physical plant tour, interviewed staff, clients reviewed medication and reviewed and obtained copies of pertinent documentation relevant to the investigation. On 04/20/2026, LPA interviewed Behaviorist Stephanie Trujillio. On 05/26/2026, LPA interviewed Tri-County Service Coordinator Marcella Poyanco.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 29-AS-20251027152644
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/19/2026
NARRATIVE
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It was reported that "staff retaliated against resident for filing a complaint" as it was alleged that Staff #1 (S1) made up a story that S1 dodged an attempted strike from Client #1 (C1) after a complaint was filed that involved C1. Interviews conducted and records reviewed reflected that on 09/26/2025, the Regional Office reviewed a self-reported incident report (SIR) dated 09/25/2025 that stated at approx. 07:30 a.m. C1 was encouraged to carry out daily living activities to prepare for day program. After 20 minutes, staff encouraged C1 again, which led to an emotional outburst. C1 began yelling at staff and attempted to hit S1, but C1 missed. S1 encouraged C1 to remain calm, which C1 eventually did then they continued to their day program. Interviews conducted with S1, three (3) staff members and two (2) residents who witnessed the incident confirmed that an altercation occurred. LPA’s interview with C1 revealed they do not recall the incident and reported no concerns regarding staff in the home at this time. Additional Interviews with three (3) clients revealed they had no concerns regarding staff at this time. LPA also interviewed three (3) family members/responsible parties of clients in care, all of whom stated they had no concerns regarding possible staff retaliation against clients at this time. LPA's interviews with Behaviorist for the home and Tri-county Service Coordinator for the home revealed they each had no concerns regarding possible staff retaliation against clients at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff retaliated against resident for filing a complaint” is deemed Unsubstantiated at this time.
It was reported that "Staff mismanaged resident's medication" as it was alleged that Administrator improperly managed C1's medications by repeatedly administering lorazepam and staff threatened to not assist C1 with medication administration. Interviews conducted and records review revealed C1's medication of Lorazepam 1 MG Tabs, take 1 tablet by mouth daily as needed for Severe anxiety was discontinued on 10/07/2025.
LPA’s review of Medication Administration Records (MARs) from October 2025 through January 2026 revealed that Lorazepam was not administered to C1 during that time. Although C1’s primary care provider issued a discontinuation order, the pharmacy continued delivering the medication to the facility through January 2026. Facility staff returned the medication to the pharmacy, and LPA observed records of unused bubble packs for C1 dated November 2025 through December 2025. On 03/20/2026, it was additionally alleged that staff threatened to withhold C1’s medication if they acted inappropriately. Interviews conducted with six (6) staff members revealed all denied refusing to assist clients with medication administration or observing any staff deny medications to residents in care. During an interview with LPA, C1 stated they did not recall any staff informing them that medication would be withheld.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20251027152644
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/19/2026
NARRATIVE
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Continued from 9099-C
LPA’s Interview with four (4) clients in care, revealed they had no concerns regarding staff assistance with medications at this time. LPA also interviewed three (3) family members/responsible parties of residents in care, all of whom stated they had no concerns regarding medication administration practices at the facility. LPA conducted a medication review for all clients in care. Medications were properly stored and appropriately documented on centrally stored medication and destruction records. No deficiencies were observed during the medication review. LPA's interviews with Behaviorist for the home and Tri-county Service Coordinator for the home revealed they each had no concerns regarding medication assistance and documentation. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff mismanaged resident's medication(s)” is deemed Unsubstantiated at this time.

It was reported that “Staff did not ensure that resident was provided an adequate amount of water while in care” as it was alleged that the Administrator influenced a physician to issue an unsafe order limiting C1's water intake. Interviews and record review revealed that since C1's admission in 2022, physician orders regarding daily water intake have varied between 1.5 liters and 3.7 liters per day. Records showed that multiple hydration orders were issued by two different medical providers following their assessments of C1. Administrator stated that they have never influenced a physician to issue, modify, or rewrite a hydration order. Physicians independently assess C1 and determine appropriate hydration levels. Administrator further stated that differing physician orders have been issued over time and that facility staff follow the most current physician order authorized for C1's care. No evidence was obtained to support the allegation that the Administrator influenced a physician to issue an order limiting C1's water intake. Records demonstrated that hydration orders were issued by licensed medical professionals based on their assessments of C1. No information was obtained indicating the facility directed, pressured, or otherwise influenced a physician's medical judgment. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not ensure that resident was provided an adequate amount of water while in care” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 29-AS-20251027152644
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/19/2026
NARRATIVE
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On 05/28/2026, LPA conducted physical plant tour, interviewed family members / responsible parties. On 06/04/2026, LPA interviewed Assistant Administrator Joyce Scott. On 05/28/2026, 06/04/2026 and 06/16/2026, LPA attempted to interview medical professionals familiar with the clients care but was unsuccessful.

It was reported that “Staff falsify documentation regarding resident” as it was alleged that the facility compiled incorrect information on Client #1 (C1)’s 2025 Annual Behavior Assessment. LPA’s interview with the facility’s behaviorist revealed that behavioral assessments and reports are based on staff documentation of observed behaviors. The behaviorist reported visiting the home weekly, maintaining regular communication with staff and residents, and reviewing monthly and quarterly behavioral reports with the family members / responsible parties, administrator, psychiatrist, and Regional Center. LPA’s review of C1’s July 2025 Annual Behavior Report indicated that C1 engaged in eight (8) incidents of physical aggression, defined as biting, punching, pushing, hitting, or kicking others. The report documented two (2) incidents in January 2025, five (5) incidents in May 2025, and one (1) incident in June 2025. Record review determined that the reported incidents were not fully supported by facility documentation. For January 2025, the report identified two (2) incidents of physical aggression, however, the facility was only able to provide documentation for one (1) incident on 01/25/2025, when C1 pushed a staff member. For May 2025, the report identified five (5) incidents of physical aggression occurring on 05/03/2025, 05/04/2025, and 05/21/2025. Facility records supported only one (1) incident of physical aggression on 05/21/2025, when C1 kicked a staff member. Documentation for 05/03/2025 reflected verbal name-calling but no physical aggression. Documentation for 05/04/2025 reflected that C1 grabbed a cup from a peer but did not engage in physical aggression. For June 2025, the report identified one (1) incident of physical aggression. Record review confirmed one (1) incident on 06/02/2025, when C1 pushed a staff member.

LPA’s interview with the Administrator and Assistant Administrator regarding the January and May 2025 documentation, reflected that the staff member who recorded the incidents is no longer employed at the facility. They reported they were unaware why the staff member documented physical aggression when records did not support that behavior and believed the staff member may have misinterpreted verbal aggression or name-calling as physical aggression. Information gathered and reviewed indicated that the July 2025 Annual Behavior Report contained five (5) incidents of physical aggression that were not supported by facility records.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2025 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20251027152644

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:
06/19/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amelia BanasTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
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5
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9
Staff retaliated against resident for filing a complaint.

Staff mismanaged resident's medication(s).

Staff did not ensure that resident was provided an adequate amount of water while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver final findings of the allegations listed above. Upon arrival LPA met staff and explained the reason for the visit. Administrator Amelia Banas arrived shortly after. On 10/30/2025, LPA conducted an initial 10-day complaint visit to investigate the allegations listed above. At approximately 09:30 a.m. LPA conducted physical plant tour, interviewed staff, residents, reviewed medication and reviewed and obtained copies of pertinent documentation relevant to the investigation. On 03/20/2026, LPA conducted a subsequent complaint visit to continue allegations listed above. At approx. 10:30 a.m. LPA conducted physical plant tour, interviewed staff, clients reviewed medication and reviewed and obtained copies of pertinent documentation relevant to the investigation. On 04/20/2026, LPA interviewed Behaviorist Stephanie Trujillio. On 05/26/2026, LPA interviewed Tri-County Service Coordinator Marcella Poyanco. On 05/28/2026, LPA conducted physical plant tour, interviewed family members / responsible parties. On 06/04/2026, LPA interviewed Assistant Administrator Joyce Scott. On 05/28/2026, 06/04/2026 and 06/16/2026, LPA attempted to interview medical professionals familiar with the clients care but was unsuccessful.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20251027152644
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/19/2026
NARRATIVE
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Continued from 9099-C

As a result, inaccurate information was included in C1’s behavioral assessment and maintained in the resident's record. Facility staff were unable to provide documentation supporting the reported incidents and acknowledged the entries may have been incorrectly documented. Based on the information obtained during the investigation, the allegation of “Staff falsify documentation regarding resident" has been substantiated at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20251027152644
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/03/2026
Section Cited
CCR
80070(a)
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The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. The requirement was not met as evidenced by:
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Licensee agreed to review section cited and provide a written plan on how to ensure future compliance then send to LPA via email by COB 07/03/2026
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Based on interviews and records review, the licensee did not comply with the regulation cited above as C1’s facility records were not maintained to be accurate and current, which posed a potential health, safety and personal rights 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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7