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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606626
Report Date: 11/23/2022
Date Signed: 11/23/2022 10:13:16 AM

Substantiated


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
11/17/2022 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20221117170430
FACILITY NAME:ARAYATA ELDERLY CAREFACILITY NUMBER:
197606626
ADMINISTRATOR:NATIVIDAD ARAYATAFACILITY TYPE:
740
ADDRESS:44849 LOTUS LANETELEPHONE:
(661) 948-4985
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 6DATE:
11/23/2022
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Marti Arayata and Zaleta NatividadTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Staff is obstructing facility door.
INVESTIGATION FINDINGS:
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On 11/23/2022 at 8:47 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct an unannounced complaint investigation. Staff #1 (S1) greeted LPA and was granted access. LPA asked S1 to contact the Administrator. Administrator Zaleta Natividad and Marti Arayata arrived shortly after. LPA explained the reason for the visit.

It was alleged staff was obstructing facility door. At approximately 9:20 a.m. the Administrator Zaleta confirmed when staff is very busy, they place a small piece of furniture against the front door to slow down a resident #1(R1) who is trying to exit the facility. The administrator said R1 is able to move the small piece of furniture, and this is only used to slow down R1 giving staff enough time to reach R1 out the door.






Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
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 3
Control Number 31-AS-20221117170430
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: ARAYATA ELDERLY CARE
FACILITY NUMBER: 197606626
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2022
Section Cited
CCR
87307(d)(6)
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87307(d) The following space and safety provisions shall apply to all facilities:(6)All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
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Administrator removed the small piece of furniture immediately on todays visit. Administrator will submit a statement about steps they will take to prevent this in the future to LPA by POC due date 11/24/2022.
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Based on interview with the Administrator on 11/23/2022. The Administrator confirmed staff is placing a small piece of furniture against the front door when they get very busy, which poses an immediate health, safety and personal rights risk to persons 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: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20221117170430
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: ARAYATA ELDERLY CARE
FACILITY NUMBER: 197606626
VISIT DATE: 11/23/2022
NARRATIVE
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LPA observed the small piece of furniture by the door. Marti Arayata removed it immediately. Therefore, the allegation is deemed SUBSTANTIATED.

Deficiencies issued during today’s visit. Refer to 9099D.

Exit interview conducted / Appeals rights provided/ A copy of the report was provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3