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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609848
Report Date: 09/28/2021
Date Signed: 09/28/2021 02:15:42 PM

Document Has Been Signed on 09/28/2021 02:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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:
09/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Amelia BanasTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived at 1:00 p.m. for an unannounced Case Management visit to the facility today in response to an incident communicated to the Department on May 12, 2021. Tri-Counties Regional Center Quality Assurance Specialist (QAS) Freddie Garcia was also present for the visit. The LPA and QAS met with Amelia Banas and explained the reason for the visit.

The facility self-reported an incident on May 12, 2021, which described Client #1 (C1) having a behavioral episode, which led to staff performing a hold on C1 until the police arrived. During today's visit, the LPA and QASinterviewed staff at 1:10 p.m. and 1:41 p.m. The LPA and QAS also discussed recent incidents pertaining to C1 from the prior weeks.

Further investigation is required at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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