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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606597
Report Date: 03/25/2022
Date Signed: 03/25/2022 05:26:47 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
03/19/2021 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20210319153913
FACILITY NAME:WESTPORT HOMEFACILITY NUMBER:
197606597
ADMINISTRATOR:MORENA MARTINEZFACILITY TYPE:
740
ADDRESS:10252 EAST AVENUE STELEPHONE:
(661) 944-5779
CITY:LITTLEROCKSTATE: CAZIP CODE:
93543
CAPACITY:20CENSUS: 12DATE:
03/25/2022
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:T. Cambiado,TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff did not notify resident's authorized representative of a change in the resident's condition



INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unannounced visit and was met by the facility manager, T. Cambiado. LPA stated the purpose of the visit was to continue the investigation regarding the complaint allegations, facility staff did not notify resident's authorized representative of a change in the resident's condition, facility staff financially abused resident, facility staff did not return resident's personal property.LPA Spaeth reviewed R1's records from 11:35 am until 12:00 noon. LPA interviewed Administrator from 12:15 until 12:30 pm and interviewed the previous administrator from 12:35 pm until 12: 45 pm.

Facility state did not notify resident's authorized representative of a change in the resident's condition,

LPA Spaeth interviewed R1's family member (F1) stated did not receive a call from the facility regarding R1's hospitalization until January 11, 2022. Investigator Edward Hector obtained and reviewed the medical records from Palmdale Regional Medical Center on May 10, 2021. According to the medical records, R1 was admitted via ambulance to the hospital on January 9, 2021. Also LPA interviewed another family

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: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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 4
Control Number 31-AS-20210319153913
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: 03/25/2022
NARRATIVE
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member (F2) who stated was never contacted by facility regarding the hospitalization of R1. Also, LPA spoke to Administrator Garabato who stated did not call family members regarding the hospitalization of R1 but thought previous Administrator had called the family members. LPA also spoke to previous Administrator who stated had not worked at the facility since 11/22/2020. Therefore based upon LPA's interview of R1's family members, Administrator and former Administrator, this allegation is substantiated.

Based on the Investigator’s review of the medical records and staff interviews and pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit interview conducted, appeal rights discussed, and a copy of the signed report was given to the Facility Manager.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa SpaethTELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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
03/19/2021 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20210319153913

FACILITY NAME:WESTPORT HOMEFACILITY NUMBER:
197606597
ADMINISTRATOR:MORENA MARTINEZFACILITY TYPE:
740
ADDRESS:10252 EAST AVENUE STELEPHONE:
(661) 944-5779
CITY:LITTLEROCKSTATE: CAZIP CODE:
93543
CAPACITY:20CENSUS: 12DATE:
03/25/2022
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:T. Cambiado,TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff financially abused resident

Facility staff did not return resident's personal property
INVESTIGATION FINDINGS:
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Facility Staff financially abused resident. - LPA Spaeth spoke to previous Administrator at 12:35 pm who stated believed R1 paid own bills but could not remember for sure. Also, LPA spoke to Administrator Garabato at 12:15 pm who thought facility received rental payment from Heritage Clinic. LPA Spaeth spoke to a Heritage Clinic Representative at 1:15 pm who stated R1 did not receive rental payment assistance from Heritage Clinic. At 11:30 am, LPA observed R1's file and observed the Physician's Report stated resident is able to manage own funds. Therefore this allegation is unsubstantied.

Facility Staff did not return Resident's personal property. - F1 had stated R1's wallet was sent to brother in Florida. F1 stated former Administrator stated wallet contained $271.38 but F1's brother stated wallet only contained $60.00. LPA interviewed Administrator at 12:35 pm who stated R1's wallet was sent fed ex to brother in Florida but stated did not know the amount of money that was incide the wallet. Therefore this allegatioon is unsubstantiated. Exit interview conducted, appeal rights discussed, and a copy of the signed report was given to the Facility Manager.

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: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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-20210319153913
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: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical condition, . When changes … are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person..
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Administrator conduct training regarding the regulations that pertain to notifying designated parties regarding the change of a resident's condition.
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This requirement was not met as evidencd by: Based on LPA's interviews of two family members. Family Member #1 stated was notified on 1/11/2021 and told R1 had been hospitalized on 1/09/2021. Family Member #2 stated had not been notified by staff regarding R1's hospitlization.
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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: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4