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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609848
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:10:45 PM

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
10/06/2023 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20231006162319
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:
04/18/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ramon JunioTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not meet resident's needs.
Illegal eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Zabel Chochian conducted a complaint visit to deliver findings regarding the above allegations.

On 10/06/2023 Community Care Licensing Division received a complaint with the following allegations:
Allegation, “Staff did not meet resident's needs”. Information was provided that the home has not provided appropriate behavioral support for the past three years to client #1(C1). Furthermore, it was reported that C1 has presented challenging behaviors and the administrator/staff have not effectively provided any behavioral support to C1.

Allegation, “Illegal eviction”. Information was provided that administrator issued an illegal 3-day eviction to C1 and responsible person on 05/13/2023 as a result of C1’s challenging behaviors.

Following is a summary of the investigation: (Continue to page LIC9099c.)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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 3
Control Number 29-AS-20231006162319
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: 04/18/2024
NARRATIVE
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On 10/09/2023, interview was conducted with administrator and staff at 6:00 p.m.; C1’s file was reviewed at 6:15 p.m. and copies of pertinent documents was obtained. Interview was conducted with a credible witness on 03/11/2024 and information was obtained in support of the allegations.

Regarding allegation “Staff did not meet resident's needs” – Interviews conducted, and records reviewed revealed that C1 has had increasing challenging behaviors since admission (8/1/2020). Administrator reported that C1 has had a history of significant problem behaviors, including physical aggression towards other clients and staff. Case was discussed with a credible witness, and it was confirmed that the behavioral plan for C1 did not show of any specific strategies to prevent, reduce, or mitigate behaviors. The reports were minimal in detail and only included a description of the behaviors without an actual behavioral plan. Neither staff or administrator were able to allude to any specific behavior strategies when questioned. The administrator confirmed that their behaviorist at the time did not provide any consultation or training on any specific strategies for staff to be able to support C1’s behaviors. Based on the information gathered allegation “Staff did not meet resident’s needs” is deemed substantiated at this time.

Regarding allegation “Illegal eviction” – Interviews conducted, and records reviewed revealed that due to C1’s increasing behaviors administrator issued a 3-day eviction notice for C1 on 5/13/2023. Subsequently, the administrator decided to rescind the 3-day notice and issue a 30-day notice to C1. According to administrator C1 presented with behaviors which put others in danger on 5/9/2023. Based on records reviewed there were no needs and service plan that was modified to indicate C1’s needs could not be met, and no actual behavioral plan noted. Based on the information gathered the allegation “Illegal eviction” is deemed substantiated.

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: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20231006162319
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: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2024
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision:(a)The licensee shall provide care and supervision as necessary to meet the client's needs.


This requirement is not met as evidenced by:
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Licensee/Administrator has since changed their BCBA and it was reported that there has been a significant change in the quality of behavioral support staff and residents are receiving now. Licensee/Administrator to provide written statement on how they will maintain in compliance with this section cited.
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Based on interviews and records reviewed- Administrator and staff were not able to state to any specific behavior strategies used to assist in meeting C1's needs. Records reviewed did not show of any specific strategies used to prevent, reduce, or mitigate C1's behaviors.
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Type B
04/18/2024
Section Cited
CCR
85068.5(b)
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Eviction Procedures (b) The licensee shall obtain prior written approval from the Department to evict the client upon three (3) days written notice to quit and upon a finding of good cause.
This requirement is not met as evidence by:
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Licensee/Administrator acknowledged understanding the eviction procedures and therefore rescinded the 3-day notice.
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Based on interviews and records reviewed - Administrator issued a 3-day notice to C1 and representative of C1 prior to consulting/obtaining approval from the department.
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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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
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