191204625-6-20-2024-31-AS-NMAN-DEHW4F-20250306155724

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191204625
Report Date: 06/20/2024
Date Signed: 06/20/2024 02:25:37 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
06/14/2024 and conducted by Evaluator Antonia Alvizar-Ettima

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20240614110353

FACILITY NAME:	SPRING MEADOWS HOME		FACILITY NUMBER:	191204625
ADMINISTRATOR:	VON BUCK, EARL A.		FACILITY TYPE:	735
ADDRESS:	43758 NORTH HARDWOOD		TELEPHONE:	(661) 942-2010
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY:	4	CENSUS: 4	DATE:	06/20/2024
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Administrators, Dacia and Earl Von Buck		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Food provided to the client was in poor quality

INVESTIGATION FINDINGS:

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At 10:50a.m Licensing Program Analyst (LPA) Antonia Alvizar- Ettima conducted an unannounced initial visit for the above noted allegation. LPA observed that clients nor staff where not at the facility. LPA contacted Administrator, Dacia via-phone and explained the reason for the visit.
Administrator,Dacia indicated that she will be arriving to the facility soon. Between 11:00a.m. – 11:20a.m. LPA interviewed administrator and Adult Day Program staff via-phone. LPA asked questions relevant to the nature of the complaint. At 11:20a.m. Administrator, Earl arrived to the facility. At 11:25a.m. LPA and Administrator, Earl conducted a physical plant tour. At 11:45a.m. LPA obtained copies of Refrigerator Cleaning Schedule, Staff and Client rosters relevant to the investigation. At 11:58a.m. LPA reviewed documents obtained.

Food provided to the client was in poor quality.
It is being alleged that staff did not check Client (C1) food prior to putting C1’s food into they lunch bag
Continue on 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

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-20240614110353

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SPRING MEADOWS HOME	FACILITY NUMBER: 191204625
	VISIT DATE: 06/20/2024

NARRATIVE

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resulting in providing C1 with moldy food.

Administrator interviews reveal that C1 attends Adult Day Program. Facility staff always provide C1 with a sandwich, hot pockets, fruit and a drink to attend the Adult Day Program. Facility staff always provide good quality food to C1 and other clients in the facility. At the Adult Day Program C1 does volunteer hours at the Food Bank were C1 is given food to take from the site. At the Food Bank C1 received expired/spoiled food and took it to the Adult Day Program. Administrators indicated that they do not receive food from the Food Bank because it is expired, or the expiration date is too soon. C1 is never given lasagna or leftover food to take to the Adult Day Program. The Adult Day Program staff interview confirm the information provided by Administrators. That C1 does volunteer hours at the Food Bank under the Work Program. The Food Bank and Adult Day Program allows C1 to take food from the site.

During the facility tour LPA observed a seven (7) day supply of non- perishable food items including pasta, cereal, canned goods, and snacks. LPA also observed a two (2) day supply of perishable food items including sandwich meat, chicken meat, milk, fruit and hot pockets. LPA visually reviewed non-perishable and perishable food items to determine if the food had expired. Upon completing the view of the food, the perishable and non-perishable items have not expired. LPA did not observed any perishable food with mold in the facility.

Based on interviews and observation there is an insufficient information to support the allegation. Therefore, allegation is UNSUBSTANTIATED at this time.

No health and safety hazard is noted during this visit.

Exit interview is conducted and copy of report was provided to Administrator.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024

LIC9099 (FAS) - (06/04)

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