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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197600845
Report Date: 07/11/2022
Date Signed: 07/11/2022 03:16:13 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
07/06/2022 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20220706162833
FACILITY NAME:APPLE STREET, LARC HOMEFACILITY NUMBER:
197600845
ADMINISTRATOR:ROSE MARIE SALGADOFACILITY TYPE:
735
ADDRESS:24624 APPLE STREETTELEPHONE:
(661) 259-2009
CITY:NEWHALLSTATE: CAZIP CODE:
91321
CAPACITY:6CENSUS: 4DATE:
07/11/2022
UNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Chris BratzelTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Staff do not have up to date training on file.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA arrived at 10:40am. LPA was screened upon entry and met with Chris Bratzel. LPA conducted a physical plant tour at 11:00am.

It was alleged that staff at the facility do not have up to date training. To investigate this allegation, on 07/11/2022 from 11:30am to 2:00pm, LPA interviewed staff and requested documents. Interviews and record review revealed that staff do not have the necessary training as required by California Code of Regulations Title 22.

Based on the information revealed during the interview and record review, the allegation is SUBSTANTIATED at this time.

(cont. on LIC 9099-C)


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
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-20220706162833
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: APPLE STREET, LARC HOME
FACILITY NUMBER: 197600845
VISIT DATE: 07/11/2022
NARRATIVE
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Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20220706162833
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: APPLE STREET, LARC HOME
FACILITY NUMBER: 197600845
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/11/2022
Section Cited
CCR
85064(b)
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85064(b) Administrator Qualifications and Duties. All adult residential facilities shall have a certified administrator.

This requirement is not met as evidenced by:
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During the visit, licensee provided proof of CEU certificates of completion for S1 and S2 who previously did not complete the required trainings.
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Based on interviews and record review the licensee did not ensure that S1 and S2 have valid Continuing Education Units (CEU) training certificates which poses a potential health and safety risk for the clients in care.
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Type B
07/11/2022
Section Cited
CCR
80065(a)
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80065(a) Personnel Requirements. Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement was not met as evidenced by:
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Licensee provided proof of DSP training registrations for S3 and S4 and agreed to submit proof of DSP training certificates immediately after completion.
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Based on interviews and record review the licensee did not ensure that S3 and S4 have Direct Support Professional (DSP) 1 and DSP 2 training while working with clients which poses a potential health and safety risk for the clients 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: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3