<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606597
Report Date: 09/28/2022
Date Signed: 09/28/2022 04:24:22 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
09/21/2022 and conducted by Evaluator Melissa Ruiz
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220921115643
FACILITY NAME:WESTPORT HOMEFACILITY NUMBER:
197606597
ADMINISTRATOR:REX RETOLADOFACILITY TYPE:
740
ADDRESS:10252 EAST AVENUE STELEPHONE:
(661) 944-5779
CITY:LITTLEROCKSTATE: CAZIP CODE:
93543
CAPACITY:20CENSUS: 12DATE:
09/28/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Russel Cambiado TIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff served resident spoiled food.
Facility did not have a staff member on duty and awake for night supervision.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/28/22 Licensing Program Analysts (LPAs) Melissa Ruiz and Joscenlyn Martinez arrived at the facility to conduct an unannounced complaint investigation. Upon arrival, LPAs were greeted by staff (S1) , LPAs later notified the Licensee Roda Garabato, and explained the purpose of the visit.

It was alleged that staff served resident spoiled food.

To investigate this allegation, LPAs conducted a walk-through of the kitchen at 11:55 a.m. and LPAs observed perishable food items in three refrigerators to be infested with dead cockroaches. Additionally, perishable food items were being stored in the refrigerators without lids or dates. LPAs observed nonperishable items stored in the kitchen cabinets were infested with live cockroaches. LPAs interviewed S1 and S1 acknowledged that various food items were infested with cockroaches and stored inadequately.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
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 6
Control Number 31-AS-20220921115643
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: WESTPORT HOME
FACILITY NUMBER: 197606597
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2022
Section Cited
CCR
87555(b)(28)
1
2
3
4
5
6
7
87555 General Food Service Requirements (b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees staff will deep clean the refrigertor, ensure all food is stored according to Title 22 Regulations, and discard any and food that is contaminated due to the cockroach infestation. Photos will be submitted by the POC due date.
8
9
10
11
12
13
14
Based on LPAs observation and an interview with S1, LPAs observed food to be contaminated and infested with dead and live cockroaches. Additionally, perishable items were observed to be stored without lids or dates. This poses an immediate health and safety risk or personal rights risk to residents in care.
8
9
10
11
12
13
14
Type A
09/30/2022
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
1
2
3
4
5
6
7
Licensee agrees there will be an updated LIC500 to reflect staff hours and availability. Licensee will ensure there is a wake-night staff at all times. An updated LIC500 and a written statement signed by licensee and staff will be submitted by the POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:

Based on interviews conducted, three out of four residents stated that there is no staff available at night to help or assist if needed. This poses an immediate health and safety risk or personal rights risk to residents in care.
8
9
10
11
12
13
14
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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 31-AS-20220921115643
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: WESTPORT HOME
FACILITY NUMBER: 197606597
VISIT DATE: 09/28/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility did not have a staff member on duty and awake for night supervision.

To investigate this allegation, LPAs interviewed one staff (S1), the Licensee, one (1) previous resident, and four (4) residents who were verbally able to communicate during today’s visit. Interviews with three (3) out of four (4) residents and one (1) previous resident revealed that they do not see staff around at night and staff are not around to help or assist if needed. Two (2) residents stated that if they were to need help at night, they are fearful that they would not be to receive assistance from any staff member. An interview with S1 revealed that staff live in the second story of the facility which is only accessible through the outside of the facility. A separate entrance was observed. Additionally, facility does not have a signal system. During today’s visit, LPAs observed a resident calling S1 on their personal cellphone for toileting needs or assistance, to which S1 confirmed that is how residents request assistance.

Staff did not dispense medication as prescribed.

During record review, LPAs oberved that there was no centrally stored medication and destruction log (LIC622) for one (1) previous resident. S2 stated that there was no LIC622 completed for the previous resident. Due to no LIC622 on record, there is no way to confirm or verify that medications were being dispensed as prescribed or properly. Additionally, during the physical plant tour, LPAs observed medications accessible to a resident (R1) in care in bedroom #1. According to an interview with S2, S2 stated that R1 can administer their own medication. However, when LPAs requested documentation, such as a physician's report (LIC602) or appraisal needs and services to reflect that R1 can administer their own medication, there was none on file and S2 stated that they have not obtained a physician's report from the physician or family member upon admission.

Based on LPAs observation and interviews, the allegations mentioned above are substantiated. Deficiencies issued per CA Code of Regulations, Title 22. See LIC9099D. Report signed by designee and delivered to licensee.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
09/21/2022 and conducted by Evaluator Melissa Ruiz
COMPLAINT CONTROL NUMBER: 31-AS-20220921115643

FACILITY NAME:WESTPORT HOMEFACILITY NUMBER:
197606597
ADMINISTRATOR:REX RETOLADOFACILITY TYPE:
740
ADDRESS:10252 EAST AVENUE STELEPHONE:
(661) 944-5779
CITY:LITTLEROCKSTATE: CAZIP CODE:
93543
CAPACITY:20CENSUS: 12DATE:
09/28/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rusell Cambiado TIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not safeguard resident's personal items
Staff are sleeping during daytime hours.
Staff berated resident.
Staff did not provide baths to resident on a regular basis.
Staff handled resident in a rough manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/28/22 Licensing Program Analysts (LPAs) Melissa Ruiz and Joscenlyn Martinez arrived at the facility to conduct an unannounced complaint investigation. Upon arrival, LPAs were greeted by staff (S1) , LPAs later notified the Licensee Roda Garabato, and explained the purpose of the visit.

Allegation: Staff did not safeguard resident's personal items

It is alleged that staff are not safeguarding residents’ personal items. To investigate this allegation LPA conducted interviews with resident, staff, and Licensee. Four (4) out of four (4) residents stated they not have any issues with their belongings not being safeguarded by staff. S1 stated the residents have not complained to staff about their belongings not being safeguarded. Additionally, S1 stated all the items belonging to resident who have moved out are returned. S1 gave the example of a resident who had recently move out and stated all of their items were returned when the movers came to collect resident’s belongings.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 31-AS-20220921115643
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: WESTPORT HOME
FACILITY NUMBER: 197606597
VISIT DATE: 09/28/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff are sleeping during daytime hours
It is alleged that staff take a nap during the daytime hours. When LPAs arrived at the facility LPAs observed three staff at the facility. All three staff were awake and providing care. Interviews with four (4) out of four (4) residents stated staff are awake during the daytime hours and do provide care and supervision to residents in care. Interviews with staff and Licensee revealed that staff are awake during the daytime hours and do not nap throughout their shifts. Based on interviews and observation these allegations are deemed Unsubstantiated.

Allegation: Staff berated resident
Allegation: Staff handled resident in a rough manner
It is alleged that staff have berated and handled resident in a rough manner. To investigate these allegations, LPAs conducted interviews with resident and staff. Interviews revealed four (4) out of four (4) residents stated the staff have not berated or have treated them in a rough manner. All residents stated the staff are good with them and have not witness staff treating other residents in a rough manner nor berating them. Based on interviews this allegation is deemed Unsubstantiated.

Allegation: Staff did not provide baths to resident on a regular basis.
It is alleged that staff do not provide baths to residents on a regular basis. It is also alleged that is a resident missing their scheduled shower time they will not receive a shower until their next scheduled shower. To investigate this allegation, LPAs interviewed residents, staff, and Licensee. One (1) out of four (4) residents stated they receive showers about three times a week. Three (3) out of (4) four residents stated they can shower whenever they want. Staff and Licensee stated residents are given showers multiple times in the week and if residents miss a shower, they will schedule them at a later time. Based on interviews this allegation is deemed Unsubstantiated.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 31-AS-20220921115643
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: WESTPORT HOME
FACILITY NUMBER: 197606597
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2022
Section Cited
CCR
87458(b)(3)
1
2
3
4
5
6
7
87458 Medical Assessment
(b) The medical assessment shall include, but not be limited to: (3) A record of current prescribed medications, and an indication of whether the medication should be centrally stored, pursuant to Section87465(h)(1).

Based on record review and an interview with S2, there was no LIC622 for one (1) previous resident, no physician’s report or appraisal needs and services for R2 which poses an immediate health and safety risk to residents in care.
1
2
3
4
5
6
7
Licensee and staff will provide an updated LIC622, and proof of requesting an updated physician reports for all residents in care shall be submitted by the POC due date.
8
9
10
11
12
13
14
This requirement is not met as evidenced by:

Based on record review and an interview with S2, there was no LIC622 for one (1) previous resident, no physician’s report or appraisal needs and services for R2 which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
CCR
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6