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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606618
Report Date: 03/29/2021
Date Signed: 03/29/2021 02:05:34 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
04/06/2020 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200406093229
FACILITY NAME:RETZEL CARE HOME IIFACILITY NUMBER:
197606618
ADMINISTRATOR:BLANCA D LOPEZFACILITY TYPE:
740
ADDRESS:9540 DONNA AVENUETELEPHONE:
(818) 993-0089
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 3DATE:
03/29/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sandra BelloTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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1. Facility is in disrepair
2. Facility is not assisting residents with basic services
INVESTIGATION FINDINGS:
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Due to the situation surrounding the Coronavirus Disease (COVID-19), and to implement mitigation measures, Licensing Program Analyst (LPA) Tuesday Cabiness delivered the final findings of the complaint investigation telephonically with the Co-Administrator Sandra Bello. The following was allegations were determined:


Allegation #1: Facility is in disrepair. Concerns were expressed, the facility was in disrepair, due to plumbing issues; periodic times of not maintaining hot water; and facility telephone and cable at times not operating. During this investigation, LPA obtained information, from a previous complaint, in March 2020, the facility had issues with hot water. According to that documentation, a citation was issued; and the facility corrected the issue. LPA conducted interviews on April 09, 2020, June 03 & 25, 2020, July 20, 2020, and March 17, 20 & 24, 2021, at various times, from 9am to 4pm. Through those interviews, it was revealed and confirmed from multiple sources, the facility had no hot water, telephone and cable was disconnected, and there continued to be plumbing issues.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
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-20200406093229
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: RETZEL CARE HOME II
FACILITY NUMBER: 197606618
VISIT DATE: 03/29/2021
NARRATIVE
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The plumbing issues affected one resident room, and the toilet could not flush. This is a health and safety risk to residents in care. Therefore, based on interviews, the allegation, “facility is in disrepair”, will be SUBSTANTIATED at this time.

Allegation #2: Facility was not assisting residents with basic services. Concerns were expressed that the facility was not assisting residents with basic services, due to the facility not sustaining hot water, and residents were not bathed and showered daily. LPA conducted interviews on April 09, 2020, June 03 & 25, 2020, July 20, 2020, and March 17, 20 & 24, 2021, at various times, from 9am to 4pm. Through those interviews, it was revealed and confirmed from multiple sources, that resident’s hygiene and personal services were not provided, due to lack of hot water in the facility. It was determined, that residents would wear the same clothing for days; smelled like urine and feces, and was not given daily showers, due to the plumbing issues and not sustaining hot water to clean residents. This is a health and safety risk to residents in care. Therefore, based on interviews, the allegation, “facility was not assisting residents with basic services”, is SUBSTANTIATED at this time.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20200406093229
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: RETZEL CARE HOME II
FACILITY NUMBER: 197606618
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2021
Section Cited
CCR
87303(a)
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Maintenance and Operation.(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met, evidenced by,
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POC cleared, at this time, there are currently no plumbing issues, telephone and cable are currently operating. And a document that the plumbing was fixed.
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based on interviews, it was confirmed, the facility had plumbing issues, no hot water, and telephone and cable was disconnected. This poses a health and safety risks to residents in care.
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Type B
04/07/2021
Section Cited
CCR
87464(f)(1)(4)
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Basic Services: (f)Basic services shall at a minimum include:(1)Care and supervision ...defined in Section 87101(c)(3) & H&S Code,section 1569.2(c). (4)Personal assistance and care as needed by the resident..indicated in the pre-admission appraisal, with those activities of daily living, such as dressing, eating, bathing, and
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Co-Administrator stated to LPA, that the facility checks the hot water daily, and if any issues occur, immediately correct the issue. The facility will create a maintenace and check list that demonstrates what has been checked monthly. Administrator will ensure those records are kept, so that Licensing can verify
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and assistance with taking prescribed medications...This requirement was not met, evidenced by, based on interviews, the facility had plumbing, no hot water, no cable or telephone service. This poses a potential health and safety risk to residents in care.
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what has been corrected. Administrartrator will forward a copy to LPA.
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: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 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
04/06/2020 and conducted by Evaluator Tuesday Cabiness
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20200406093229

FACILITY NAME:RETZEL CARE HOME IIFACILITY NUMBER:
197606618
ADMINISTRATOR:BLANCA D LOPEZFACILITY TYPE:
740
ADDRESS:9540 DONNA AVENUETELEPHONE:
(818) 993-0089
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 3DATE:
03/29/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sandra BelloTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility was not providing diet prescribed by resident’s physician
INVESTIGATION FINDINGS:
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Due to the situation surrounding the Coronavirus Disease (COVID-19), and to implement mitigation measures, Licensing Program Analyst (LPA) Tuesday Cabiness delivered the final findings of the complaint investigation telephonically with the Co-Administrator Sandra Bello. The following was allegations were determined:

Allegation: Facility was not providing prescribed diet by resident’s physician. Concerns were expressed that resident # 1 (R1) was not provided a prescribed diet by R1’s physician. LPA conducted interviews on April 09, 2020, June 03 & 25, 2020, July 20, 2020, and March 17, 20 & 24, 2021, at various times, from 9am to 4pm, and obtained documentation pertaining to R1. It was reported to LPA, that R1, required specific liquids, that were prescribed by R1’s physician. LPA reviewed R1’s medical and client file records. Although, documents reported a specific illness for R1, there was not specific documentation from the physician, that R1 required specific liquids. It was also revealed to LPA, that R1 did receive the specific liquid; but not based on medical documentation. Therefore, at this time, there is not sufficient evidence that the facility did not provide prescribed diet for R1, and the allegation is UNSUBSTANTIATED at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4