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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602540
Report Date: 11/06/2024
Date Signed: 11/06/2024 03:47:53 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
02/28/2024 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20240228142941
FACILITY NAME:PRESTIGE ASSISTED LIVING AT LANCASTERFACILITY NUMBER:
197602540
ADMINISTRATOR:MINDY MENDOZA-PERRYFACILITY TYPE:
740
ADDRESS:43454 30TH STREET WESTTELEPHONE:
(661) 949-2177
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:68CENSUS: 46DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Analilia Zaragoza (Administrator)TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not have planned activities for the residents.
Staff have inadequate record keeping for a resident.
Staff does not meet the minimum qualifications required.
INVESTIGATION FINDINGS:
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On 11/06/24 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival LPA met with the Administrator, Analilia Zaragoza and LPA explained the purpose of the visit was to continue the investigation on the above mentioned allegations.

On 02/29/24 LPA Melissa Spaeth conducted a physical plant tour and gathered, the resident roster and staff work schedule. On 03/28/2024 LPA Rios conducted a subsequent visit that consisted of a physical plant tour, obtaining and reviewing copies of the facility's Activity Program Description, the Activity Calendar posted for the month and also conducted interviews with five (5) residents and four (4) staff. On 11/06/2024 LPA Rios reviewed resident #2 's (R2's) financial records in regards to facility payments and obtained copy of administrator certificate.

(Continue to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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-20240228142941
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: PRESTIGE ASSISTED LIVING AT LANCASTER
FACILITY NUMBER: 197602540
VISIT DATE: 11/06/2024
NARRATIVE
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(Continued from LIC9099)
Allegation: Staff do not have planned activities for the residents. Regarding the allegation, it was reported there is a lack of activities during the week, and there are no activities during the weekend for residents.
LPA Rios review of the facility’s activity calendar and it revealed various activities throughout the week. LPA Speath and LPA Rios both observed activities going on during visits. LPA Speath observed a musician and LPA Rios observed a knitting group. Activities on calendar and activities observed by LPAs are on par with the Activity Program Description. Interview with Executive Director on 03/28/24 denies the allegation stating the activity calendar is posted for residents to see and it is up to the residents if they would like to participate. Interviews conducted with five (5) residents on 03/28/24 confirmed the facility does have activities some stating they participate others stating they prefer not to. Four (4) staff interviewed on 03/28/24 also confirmed facility has different activities for residents. Based on interviews and observations this allegation is deemed Unsubstantiated.

Allegation: Staff have inadequate record keeping for a resident. Regarding the allegation, it was reported an admission payment for resident#2 (R2) was misplaced or unaccounted for. LPA Rios review of R2's financial record revealed facility listed deposit amount as paid with dates on form and copy of check consistent with admission date. LPA also observed R2 was set up for direct deposit during their first month of admission with a copy of a void check on file. LPA attempted to interview R2 on 11/05/24 during the facilities annual inspection, but resident did not respond to questioning. Interview with administrator on 11/06/24 denies any issues with payments and also confirmed resident is up to date with payments and currently has a zero balance due. Based on interview and record review this allegation is deemed Unsubstantiated.

Allegation: Staff does not meet the minimum qualifications required. Regarding the allegation, it was reported the current administrator does not currently possess a valid RCFE certification. To investigate the allegation on 02/29/24 LPA Spaeth obtained a copy of a print out from the Administrator Certification Bureau website showing Analilia's certification is active. On 03/28/24 LPA Rios review of correspondence between CCL and the facility revealed facility had informed the department on 04/01/22 that Analilia Zaragoza would be Executive Director submitted required documentation to for change of administrator. On 01/05/2024, CCL received notification Analilia will be Interim Executive Director. Review of records revealed Administrator Certificate on file for current Administrator and Executive Director. Based on interview and record review this allegation is deemed Unsubstantiated.

Exit interview was conducted. A copy of the report provided.

SUPERVISOR'S NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3