191202146-4-22-2022-31-AS-NMAN-CGHVZA-20220720165224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191202146
Report Date: 04/21/2022
Date Signed: 04/22/2022 09:34:41 AM

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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2022 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20220419142152

FACILITY NAME:	TWELVE OAKS		FACILITY NUMBER:	191202146
ADMINISTRATOR:	DENISE M GOTTO		FACILITY TYPE:	740
ADDRESS:	2820 SYCAMORE AVE		TELEPHONE:	(818) 862-0811
CITY:	LA CRESCENTA	STATE: CA	ZIP CODE:	91214
CAPACITY:	63	CENSUS: 32	DATE:	04/21/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Denise Gotto, Executive Director		TIME COMPLETED:	05:38 PM

ALLEGATION(S):

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Facility is not providing assistance in meeting resident's medical needs including transportation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint investigation for the above noted allegation. LPA met with Denise Gotto, Executive Director. and discussed the purpose of the visit.

It was reported that facility is not providing assistance in meeting resident's medical needs including transportation. To investigate this allegation, LPA Valenzuela conducted an unannounced visit on 04/21/2022 and between 1:45pm and 2:24pm initiated staff interviews. Staff interviews revealed that on 01/14/2022, facility E.D. sent a letter out to residents and their families indicating that complimentary transportation services would no longer be offered and that this would become effective 03/15/2022. The letter also stated that the facility can continue to arrange transportation services for the residents at the residents own expense. The facility also offered to provide a list of vendors to the residents.

Continue- See 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

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 31-AS-20220419142152

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: 04/21/2022

NARRATIVE

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At 2:32pm, LPA interviewed Resident #1 (R1). Interviews revealed that they came to the community last year. They chose the facility because E.D. told them that they provided transportation to medical appointments. E.D. informed R1 orally, but not in writing that transportation could be provided within a ten mile radius to go to medical appointments.

Between 2:50pm and 3:30pm, LPA reviewed R1's admission agreement and physician's report. Documents revealed that R1 can take their own medication without assistance. R1 is also ambulatory and health status is listed as good. Review of R1's admission agreement revealed the basic service monthly fee and all other services provided. In regards to services provided as part of the monthly fee, it did not include transportation only mentioned arrangements for transportation to meet "health needs" ( i.e. doctors appointments) and planned activities within a ten mile radius could be provided.

Based on the information obtained through interviews and record review this allegation is deemed to be UNSUBSTANTIATED at this time.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC9099 (FAS) - (06/04)

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