567609848-9-9-2025-29-AS-KHEN-DLZT2P-20250930142103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609848
Report Date: 08/22/2025
Date Signed: 09/09/2025 10:18:16 AM

Unsubstantiated

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
04/24/2025 and conducted by Evaluator Quoc Huynh

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20250424143601

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:	DATE:	08/22/2025
		UNANNOUNCED	TIME BEGAN:	09:51 AM
MET WITH:	Ramon Junio - Administrator		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

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Staff did not ensure resident's care needs were being met.
Staff did not adequately supervise resident.
Staff spoke to resident in an inappropriate manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Quoc Huynh conducted a subsequent complaint visit to deliver findings for the above allegations. LPA arrived at 9:51AM and met with Administrator Ramon Junio and explained the reason for the visit. Entrance interview conducted.

On 04/25/2025, LPA Brian Balisi conducted an initial complaint visit. Beginning at 10:25AM, LPA Balisi conducted a physical plant tour, interviewed staff, and reviewed and obtained pertinent documents.

On 08/13/2025, LPA Huynh reviewed and obtained pertinent documents at 9:49AM and conducted a physical plant tour at 10:26AM. No immediate concerns were observed.

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

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-20250424143601

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: 08/22/2025

NARRATIVE

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During today’s visit, the LPA and Administrator conducted a safety check tour at 10:09AM. No immediate concerns were observed at this time. The LPA attempted one (1) resident interview. The following was then determined:

Allegations: “Staff did not ensure resident’s care needs were being met,” “Staff did not adequately supervise resident,” and “Staff spoke to resident in an inappropriate manner.”

It was reported that staff did not monitor Resident #1’s (R1) condition, such as preventing R1 from drinking excessive water or regulating R1’s showers, and that staff were observed sleeping at night. It was also reported that staff spoke to R1 inappropriately, making demeaning comments.

R1 was diagnosed with psychogenic polydipsia and is known to consume liquids when agitated. The Licensee reported that excessive water intake can cause seizures if unregulated. On 09/03/2024, R1’s Conservator requested a Physician to increase R1’s water intake from 2 liters to 3.7 liters per day. R1’s initial water intake restriction upon admission in 2022 was 1.5 liters. The Conservator also expressed a preference for R1 to take showers every three (3) days to control water access; however, this was a personal preference and not supported by physician orders or an intervention plan. Shower logs in the month of April 2025 showed R1 took a total of eleven (11) showers; R1 took four (4) showers between 04/11/2025 and 04/13/2025. While the facility attempted to follow the Conservator’s preference by limiting the number of showers, staff stated that declining R1 a shower would violate R1’s personal rights.

The Licensee acknowledged that R1 occasionally exceeds the suggested water intake amount and will find ways to access water despite having 1:1 staffing. When agitated, R1 would seek water and lock themselves in the bathroom, requiring staff to verbally redirect R1. Staff #1 (S1) and Staff #2 (S2) stated R1 typically returns to the facility from their Day Program with a large soda in addition to another consumed during the Program. The facility is unable to regulate R1’s water intake when they are at Day Program.

Report Continued on LIC 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250424143601

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: 08/22/2025

NARRATIVE

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Staff #3 (S3) confirmed the facility followed the 3.7 liters intake recommendation. However, staff noted that when R1’s Conservator visits, they return with a Big Gulp from 7-11. The facility’s staff also weigh R1 several times a day to monitor R1’s water intake through their weight, as requested by the Conservator.

R1 stated hearing voices that tell them “to do bad things,” but staff would redirect R1. This redirection reportedly helped R1 manage their emotions and prevent behavioral outbursts that could lead to unsafe water intake. R1 reported they had not observed or experienced staff speaking inappropriately to them or other residents. Five (5) out of five (5) staff reported using behavioral redirection techniques which included explaining to R1 their behavior and consequences if R1 were to consume too much water, per R1’s Behavior Intervention Plan. The facility documented R1’s behavior and unsafe water access on a monthly behavior data sheet.

In the month of April 2025, R1 was reported to have unsafe water access and emotional outbursts the most between 2PM and 10PM. During this time, the facility scheduled three (3) to four (4) staff on shift, with one (1) to four (4) staff scheduled as a 1:1 for R1. The facility operates 24/7 with up to three (3) overnight staff in addition to the residents’ 1:1 staff. R1 reported staff were asleep during an overnight shift, however R1 could not confirm if their eyes were closed and stated the staff were “sitting there and not moving”. Overnight staff—S3, Staff #4 (S4), and Staff #5 (S5)—each stated they do not sleep during their shift.

Although the allegations may have happened or are valid, there is not sufficient evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time.

No deficiency cited. Exit interview conducted. A copy of the report was reviewed and provided.

This report was amended due to an incorrect date. LPA spoke with Administrator Amelia Banas via telephone who was unavailable and designated Staff Mariam Nabuli to sign the amended report.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Quoc Huynh
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025

LIC9099 (FAS) - (06/04)

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