567609848-7-3-2025-29-AS-KHEN-DJZTD5-20250728143747

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609848
Report Date: 07/03/2025
Date Signed: 07/03/2025 02:24:37 PM

Unsubstantiated

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
06/30/2025 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20250630142822

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:	07/03/2025
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Amelia Banas		TIME COMPLETED:	02:28 PM

ALLEGATION(S):

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Facility staff are not preventing physical altercations between clients
Licensee does not ensure facility telephone is maintained in proper working order
Licensee does not ensure staff are adequately trained

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek, along with Investigations Branch (IB) Investigator Rocio Flores conducted an unannounced complaint visit to investigate the allegations listed above. Upon arrival, LPA and Investigator met with staff and explained the reason for the visit. Administrator Amelia Banas arrived shortly after. Entrance interview conducted.

At 09:45AM, LPA, Investigator and facility staff toured the facility. LPA and Investigator conducted an interview with the Administrator at 09:52AM, staff and client interviews from 11:20AM to 12:25PM. LPA and Investigator also reviewed relevant documents including but not limited to: client files and staff training; LPA obtained copies of pertinent documents. The following was then determined:

Allegation: "Facility staff are not preventing physical altercations between clients:"
LPA reviewed a copy of an incident report dated 06/23/2025, which indicates Client #1 (C1) had just
Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250630142822

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: 07/03/2025

NARRATIVE

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returned to the facility and was upset. Although staff attempted to redirect C1, they continued shouting and cursing, which upset another client. The other client then hit C1 on their back. According to staff interviewed, C1 provoked the other client, telling the other client to hit C1 and using curse words with the other client. Staff redirected the other client to their room, however, the other client returned to the common area and hit C1 before staff could stop the client. Interview with C1 revealed that staff were present at the time of the incident and staff did attempt to intervene. Record review revealed that staff do have training in de-escalation techniques and behavioral intervention. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Allegation: "Licensee does not ensure facility telephone is maintained in proper working order:"
The complaint alleges that the facility telephone does not work intermittently. Interviews revealed that the clients in the home frequently unplug the corded phone, causing it to not function properly. During today's visit, LPA called the facility phone, it rang and was functional. Staff interviews revealed that when a client reports the phone is non-functional, the staff check on it and plug it back in so the clients can use the phone. Staff did state that when a client has had a behavior and have broken the phone, it is replaced right away by the licensee. During today's visit Licensee arrived at the facility with supplies. Additionally, staff stated that clients' families have the staff phone number and can contact them to get ahold of the clients when needed. Clients interviewed stated the staff fix the phone and they had no concerns with telephone accessibility. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Allegation: "Licensee does not ensure staff are adequately trained:"
During today's visit, LPA and Investigator reviewed staff files for 4 (four) staff. All staff training reviewed was complete. Staff interviews revealed that all staff have ongoing training including client-specific training through the behaviorist. All staff are trained on each client's individual behaviors and needs. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

No citations issued. Exit interview conducted. A copy of today's report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025

LIC9099 (FAS) - (06/04)

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