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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197605091
Report Date: 10/13/2021
Date Signed: 10/13/2021 05:17:58 PM



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
10/07/2021 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20211007151233
FACILITY NAME:YONG CARE HOMEFACILITY NUMBER:
197605091
ADMINISTRATOR:GARY JOHNSONFACILITY TYPE:
740
ADDRESS:1539 W. AVENUE L-12TELEPHONE:
(661) 916-9351
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 2DATE:
10/13/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Gary JohnsonTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Dangerous items are accessible to residents.
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unnanounced visit and arrived at 3:00 pm and was greeted by Administrator, Gary Johnson. LPA Spaeth stated the reason for the visit is regarding a complaint which states dangerous items are accessible to residents and medications are not locked at the facility. Upon arrival, LPA observed Administrator and caregiver were both wearing masks. LPA's temperature was taken and recorded. LPA Spaeth began tour at 3:04 pm and observed a resident who was watching television in the living room. LPA observed the residents' rooms contained the necessary items bed, linens, lamp, night stand and chest of drawers.

LPA observed the bathrooms which contained wash your hands sign, hand soap, paper towels but observed at 3:10 pm cleaning solutions were under the bathroom sink but not locked. LPA Spaeth stated Title 22 Regulations state all hazardous cleaning supplies must be locked. At 3:15 pm, LPA observed Administrator
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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 4
Control Number 31-AS-20211007151233
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: YONG CARE HOME
FACILITY NUMBER: 197605091
VISIT DATE: 10/13/2021
NARRATIVE
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solutions must be locked. At 3:15 pm LPA observed caregiver locked the cleaning supplies in the laundry area. LPA was then escorted to the kitchen and observed wash hands sign, hand soap, and paper towels. However, LPA observed the knives were not locked in the kitchen drawer. At 3:24 pm LPA observed Caregiver, Yong Johnson locked the knives in the kitchen cabinet.

From 3:30 pm until 3:40 pm, LPA reviewed residents files. LPA observed resident's (R1) file and noted R1's physician assessment stated R1 had been diagnosed with dementia.

Per Title 22 Regulations, the following deficiencies were issued on the following 809-D page.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
10/07/2021 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20211007151233

FACILITY NAME:YONG CARE HOMEFACILITY NUMBER:
197605091
ADMINISTRATOR:GARY JOHNSONFACILITY TYPE:
740
ADDRESS:1539 W. AVENUE L-12TELEPHONE:
(661) 916-9351
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 2DATE:
10/13/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Gary JohnsonTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Medications are not locked at the facility
INVESTIGATION FINDINGS:
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During the tour, LPA Spaeth observed the medications were securely locked in a kitchen cabinet. LPA observed two plastic bins in the cabinet which each contained the medications for the residents. Therefore the above allegation, medications are not locked at the facility is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20211007151233
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: YONG CARE HOME
FACILITY NUMBER: 197605091
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2021
Section Cited
CCR
87309(a)
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(a) Disinfectants, cleaning solutions, poisons... which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is evidenced by:
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During the LPA's tour of the facility, LPA Spaeth observed Caregiver securely locked the cleaning solutions in a locked cabinet.
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LPA Spaeth observed the cleaning solutions were not securely locked in a cabinet which poses an immediate health, safety, and personal rights risk to residents in care.
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Type B
10/13/2021
Section Cited
CCR
87705(f)(1)
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(f) The following shall be stored inaccessible to residents with dimentia: (1) Knives, matches,.... that could constitute a danger to the resident(s). This requirement is not evidenced by:
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During the LPA's tour of the facility, LPA Spaeth observed Caregiver securely locked the knives in a locked cabinet.
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LPA Spaeth observed the knives were not securely locked in a cabinet which poses an immediate health, safety, and personal rights risk 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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4