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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 04:06:22 PM

Unsubstantiated


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's personal rights were violated
INVESTIGATION FINDINGS:
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on 01/10/2023 at 1:43 p.m. Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit for the above allegation. LPA met with the Licensee Wanda Smith and explained the reason for today’s visit.

During the initial visit on 12/13/2022, LPA reviewed facility records, obtained copies of pertinent documents relevant to the investigation and conducted an interview with the administrator. On 01/10/2023 from 2:20 p.m. to 3:00 p.m. LPA conducted interviews with two (2) out of three (3) residents in care. Regarding the allegation that Resident #1's (R1) personal rights were violated: it is alleged Administrator "went through R1's personal belongings". LPA interview with Administrator revealed the first day R1 came to the facility they had three trash bags of clothes. Administrator stated they were helping R1 put their belongings away with R1 present and R1 was selecting items to keep and items to throw away. Administrator stated they continued putting belongings away the next day. Interviews with Resident #2 and Resident #3 revealed administrator has never gone through their personal belongings. (LIC 9099C continued)
Unsubstantiated
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 2
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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Based on the information gathered during the investigation, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
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 2