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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602356
Report Date: 01/10/2023
Date Signed: 01/10/2023 04:04:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
12/06/2022 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20221206132655
FACILITY NAME:ANA RESIDENTIAL CAREFACILITY NUMBER:
197602356
ADMINISTRATOR:SMITH, WANDAFACILITY TYPE:
740
ADDRESS:1046 EAST LANCASTER BOULVARDTELEPHONE:
(661) 949-0151
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:6CENSUS: 3DATE:
01/10/2023
UNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Wanda SmithTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Resident was wrongfully evicted
INVESTIGATION FINDINGS:
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On 1/10/2023 at 1:48 p.m. Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit. LPA was greeted by Licensee Wanda Smith and a tour of the facility was conducted.

Allegation: Resident was wrongfully evicted: It is alleged that the administrator did not issue an eviction notice to resident #1 (R1). On 12/13/22 LPA conducted interviews, reviewed, and obtained documents pertinent to the investigation. A review of the documents on 12/13/2022 revealed no eviction notice on file for R1. On 12/13/22 the Administrator confirmed an eviction notice was not issued because the client was at the facility for less than 24 hours. On 12/13/22 the Administrator provided text message conversations between herself, R1’s, case manager #1 (CM1) and case manager #2 (CM2). The text messages reveal, non-verbatim; Administrator found drug paraphernalia among R1’s belonging and notified CM1 and CM2. (LIC 9099C Continued)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
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-20221206132655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANA RESIDENTIAL CARE
FACILITY NUMBER: 197602356
VISIT DATE: 01/10/2023
NARRATIVE
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On 12/13/2022 Administrator stated R1's substance abuse was withheld from physician's report. Administrator states CM2 agreed to remove client from facility and administrator states they would have kept R1 in the facility if no other option was available. Based on the information obtained this allegation is deemed Substantiated at this time. Deficiency cited on LIC 9099 D.
Exit Interview conducted. Copy of this report provided. Appeal Rights provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20221206132655
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANA RESIDENTIAL CARE
FACILITY NUMBER: 197602356
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited
CCR
85068.5(a)(4)
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(a) The licensee shall be permitted to evict a client by serving the client with a 30-day written notice...for any of the following reasons: (4)...the client's needs cannot be met by the facility...The licensee did not comply with the above cited section, as evidenced by:
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The Administrator will review Section 85068.5(a)(4) and will submit to LPA a written explanation on how they will assure to follow Title 22 Regulations with regards to following requirements by POC date 01/20/2023.
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Based on interviews conducted facility failed to provide R1 with a proper eviction notice which posed a potential health and safety risk and violation of Personal Rights 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: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3