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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191204625
Report Date: 01/26/2023
Date Signed: 01/26/2023 12:37:36 PM

Substantiated


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
01/18/2023 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20230118100931
FACILITY NAME:SPRING MEADOWS HOMEFACILITY NUMBER:
191204625
ADMINISTRATOR:VON BUCK, EARL A.FACILITY TYPE:
735
ADDRESS:43758 NORTH HARDWOODTELEPHONE:
(661) 942-2010
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 4DATE:
01/26/2023
UNANNOUNCEDTIME BEGAN:
07:15 AM
MET WITH:Susie Lara and Rick HillTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Staff provided client with poor quality food
INVESTIGATION FINDINGS:
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LPA conducted an unannounced visit and was greeted by caregiver. LPA stated the purpose of the visit was regarding a complaint which states staff provided client with poor quality food. LPA observed the COVID sign on the door and the caregiver was wearing a mask. LPA was greeted by all four residents who are preparing to go to the adult day program. LPA interviewed three residents at 7:20 am until 7:40 am. LPA interviewed caregiver at 7:40 am until 7:50 am. At 7:55 am, a caregiver arrived and stated Administrator was out of town today.

LPA toured the facility with both caregivers at 7:55 am until 8:13 am. LPA oberved a seven day supply of non- perishable food items including pasta, cereal, canned goods, and snacks. LPA also observed a two-day supply of perishable food items. During the tour, LPA visually reviewed non-perishable food items and the perishable items to determine if the food had expired. Upon completing the view of the food, the perishable and non-perishable items have not expired. Caregiver confirmed that after the incident occurred, caregiver removed the expired food after the incident.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
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 3
Control Number 31-AS-20230118100931
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: SPRING MEADOWS HOME
FACILITY NUMBER: 191204625
VISIT DATE: 01/26/2023
NARRATIVE
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During LPA's tour, LPA observed the bathrooms which contained hand soap, paper towels, and a trash can. LPA observed the residents' rooms which contained all the required items such as lamp, night stand, bed, linens, and chest of drawers. LPA did not observe any health or safety issues.

LPA interviewed Administrator by phone at 8:15 am until 8:30 am regarding the complaint. Administrator confirmed the two residents did take spoiled food on January 23, 2023 to the adult day program for lunch. Administrator had received a call from the North Los Angeles Regional Center Staff member who stated the food was spoiled and had an odor. The Administrator also received a snapshot of the food item. The Administrator stated that the Regional Center staff member threw out the food and provided soup for the residents. Based upon LPA's interview of Resident 1 and interview of the Administrator, the incident did occur.

Under Title 22 General Regulations, the following citation was issued and recorded on LIC 809D.

Exit interview was conducted, appeal rights discussed and a copy of the signed report was given to the caregiver.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20230118100931
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: SPRING MEADOWS HOME
FACILITY NUMBER: 191204625
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2023
Section Cited
CCR
80076(a)(18)
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80076 Food Service: (a) In facilities providing meals to clients, the following shall apply: (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately. This is evidenced by:
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Administrator will provide training for staff regarding food safety protocol and will provide LPA with the content of the training via email.
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Based upon the resident interview and Administrator's interview, the caregiver failed to ensure the residents' food was not spoiled, which poses an immediate health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3