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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609848
Report Date: 04/16/2025
Date Signed: 04/16/2025 12:33:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
12/02/2024 and conducted by Evaluator Erica Mosley
COMPLAINT CONTROL NUMBER: 29-AS-20241202095655
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:
04/16/2025
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Amelia Banas - Administrator TIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff are not providing adequate supervision for residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Erica Mosley and Quoc Huynh conducted an unannounced subsequent complaint visit to investigate the above allegations. The purpose of this visit is to deliver findings for the above allegations. Upon arrival at 9:29 a.m., LPA Mosley and Huynh were greeted by Staff who called the Administrator. The Administrator arrived at 9:54 am. The LPAs met with Administrator, Amelia Banas and explained the reason for the visit.
On 12/02/2024 the Department received a complaint regarding the following allegation Staff are not providing adequate supervision for residents in care. On 12/06/2024 LPA Brian Balisi conducted the initial 10-day complaint visit. At approx. 12:40pm, LPA conducted a physical plant tour, interviewed one (1) staff, and the Administrator, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 3/13/2025 at 11:25 a.m. LPA Mosley conducted a telephonic interview with Witness #1 (W1) who provided Ring video footage of the incident. On 4/15/2025 starting at 5:07p.m. – 5:40p.m. LPA Mosley conducted three (3) telephonic interviews with staff.
Report continued on LIC 9099-C page 2....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
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-20241202095655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: JJ RESIDENTIAL CARE III
FACILITY NUMBER: 567609848
VISIT DATE: 04/16/2025
NARRATIVE
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(Page 2) Report continued from LIC 9099...
On 12/02/2024 the Department received a complaint regarding the following allegation Staff are not providing adequate supervision for residents in care. On 12/06/2024 LPA Brian Balisi conducted the initial 10-day complaint visit. At approx. 12:40pm, LPA conducted a physical plant tour, interviewed one (1) staff, and the Administrator, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 3/13/2025 at 11:25 a.m. LPA Mosley conducted a telephonic interview with Witness #1 (W1) who provided Ring video footage of the incident. On 4/15/2025 starting at 5:07p.m. – 5:40p.m. LPA Mosley conducted three (3) telephonic interviews with staff.

During today’s visit, at 9:50 a.m. LPAs conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. Starting at 9:37 a.m. LPAs conducted an interview with (1) staff and Administrator, brief file review and obtained copies of pertinent documents relevant to the investigation.

On the allegation Staff are not providing adequate supervision for residents in care it is the concern of the reporting party (RP) that the facility staff did not adequately supervise Resident #1 (R1), who was left unattended in the community, leading to intervention by local law enforcement. To investigate this complaint, LPAs conducted in person interviews with two (2) staff and the Administrator, telephonic interviews with three (3) staff and W1,reviewed documents and video footage relevant to the investigation. Video footage obtained revealed that the incident occurred on 11/29/2025 at 13:16:20 PST – 13:17:27 PST where R1 is at the front door of a neighboring home unattended by staff. From the video footage there were no staff in sight. Interview with staff revealed that R1 had eloped and was unsupervised by staff. R1 returned to the facility by police escort. Interview with the Administrator revealed that R1had eloped without staff knowledge and returned by police escort. Interview with W1 revealed that R1 was out in the community without any staff supervision. Record review revealed that R1 requires one to one supervision 24 hours a day. Based on interviews, video footage, and file review there is sufficient evidence to support the allegation occurred. Therefore, the allegation Staff are not providing adequate supervision for residents in care is deemed substantiated at this time.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and / or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Report was reviewed. A copy and appeal rights were issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20241202095655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JJ RESIDENTIAL CARE III
FACILITY NUMBER: 567609848
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2025
Section Cited
CCR
85065.5
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(a)…the following minimum staffing requirements shall be met: (1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center…This requirement was not met as evidenced by: Based on interviews ...
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Licensee submitted a staffing schedule with adequate staffing coverage per TCRC ratio's on the day of the visit. POC cleared.
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the licensee did not comply with the section cited above as R1 requires 1:1 support and was left unsupervised by staff, which posed 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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3