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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191202146
Report Date: 05/12/2021
Date Signed: 05/12/2021 02:28:59 PM



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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2020 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20200504131226
FACILITY NAME:TWELVE OAKSFACILITY NUMBER:
191202146
ADMINISTRATOR:DENISE M GOTTOFACILITY TYPE:
740
ADDRESS:2820 SYCAMORE AVETELEPHONE:
(818) 862-0811
CITY:LA CRESCENTASTATE: CAZIP CODE:
91214
CAPACITY:63; 63CENSUS: 28DATE:
05/12/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Denise GottoTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Staff handled resident in a rough manner
Staff spoke inappropriately to resident
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Wendell Smith made an unannounced subsequent complaint visit to finish investigation into the allegations above. LPA met with administrator Denise Gotto and explained the reason for this visit.

Staff handled resident # 1 (R1) in a rough manner and staff spoke inappopriately to R1
LPA previously conducted the initial complaint visit on 5/6/2020 and spoke with the administrator regarding these two allegations. Today LPA interviewed the administrator regarding this allegation again. LPA also had previously interviewed R1's responsible person. Information from the interviews revealed that the administrator was notified that staff #1 (S1) may have handled R1 in a rough manner. The administrator conducted an investigation and conducted interviews with other residents and staff. Information from the administrators investigation revealed that only two residents felt that S1 handled them roughly out of all the residents. Staff stated although they did not witness S1 handle any residents roughly they witnessed on occasion S1 speak in rude tones to residents on different occasions.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
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 5
Control Number 31-AS-20200504131226
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TWELVE OAKS
FACILITY NUMBER: 191202146
VISIT DATE: 05/12/2021
NARRATIVE
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Upon receiving the information the administrator made the decision to terminate S1's employment due to the nature of the allegations. Administrator had a body check done on R1 and there was no sign of injury or that R1 was being abused. LPA was not able to interview R1 due to R1 having passed away in January 2021. LPA reviewed R1's facility file and obtained copies of pertinent information. Based on the information obtained from an interview with the administrator both of these allegations are deemed Substantiated at this time. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/04/2020 and conducted by Evaluator Wendell Smith
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200504131226

FACILITY NAME:TWELVE OAKSFACILITY NUMBER:
191202146
ADMINISTRATOR:DENISE M GOTTOFACILITY TYPE:
740
ADDRESS:2820 SYCAMORE AVETELEPHONE:
(818) 862-0811
CITY:LA CRESCENTASTATE: CAZIP CODE:
91214
CAPACITY:63; 63CENSUS: 29DATE:
05/12/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Denise GottoTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Staff mismanaged resident's medication
Staff did not safeguard resident's funds
INVESTIGATION FINDINGS:
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3
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5
6
7
8
9
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12
13
Licensing Program Analyst (LPA) Wendell Smith made an unannounced subsequent complaint visit to finish investigation into the allegations above. LPA met with administrator Denise Gotto and explained the reason for this visit.
Staff mismanageed resident #1 (R1) medication
LPA previously conducted the initial complaint visit on 5/6/2020 where LPA conducted an interview with the administrator. It is alleged that R1 was without her medication for a few days due facility not ordering it. LPA reviewed R1's facility file which included medication information. LPA also conducted an interview with the administrator and R1's responsible person. Interviews revealed that R1 would call their physician without the facility knowing and put a stop to their medication. Facility then contacted R1's doctor and informed them that R1 was not able to make medical decisions on their own and had a medical power of attorney that was sent to the doctor. Based on the information obtained this allegation is deemed Unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20200504131226
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TWELVE OAKS
FACILITY NUMBER: 191202146
VISIT DATE: 05/12/2021
NARRATIVE
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Staff did not safeguard resident's funds
It is alleged that R1 had fifty dollars missing from their room. LPA conducted an interview with the administrator and R1's responsible person. Information revealed that R1's responsible person handled R1's finances and they were not aware of R1 having any money. Administrator stated they were never made aware of any money missing from R1 or that R1 carried any money. LPA was unable to interview R1 regarding this allegation due to R1 passing away. Based on the information obtained through interviews this allegation is deemed Unsubstantiated at this time.

Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20200504131226
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TWELVE OAKS
FACILITY NUMBER: 191202146
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2021
Section Cited
CCR
87468.1(a)(1)
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Personal Rights
To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by:
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Corrected before visit. Administrator had S1 who was accused of handling residents roughly and speaking with them in a rude manner let go from their position when the allegations of abuse took place.
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Based on interviews conducted residents were spoken to in a rude manner by facility staff and may have been handled roughly which posed an immediate health and safety risk to residents.
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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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5