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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606738
Report Date: 10/22/2024
Date Signed: 10/22/2024 11:14:06 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
10/17/2024 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20241017105841
FACILITY NAME:AQUAMARINE RETIREMENT HOMEFACILITY NUMBER:
197606738
ADMINISTRATOR:MARICAR MEDINAFACILITY TYPE:
740
ADDRESS:6523 W. AVENUE L-7TELEPHONE:
(661) 418-0715
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 4DATE:
10/22/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Maricar MedinaTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Staff do not properly dispose facility trash.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint visit to investigate the allegation above. LPA was greeted by staff #1 (S1) and staff #2 (S2). S2 contacted the administrator and informed them LPA was at the facility. LPA spoke to the administrator Maricar Medina via telephone and explained the reason for the visit. Administrator stated they would meet LPA at the facility.

Allegation: Staff do not properly dispose facility trash. In regards to the allegation, it was reported trash bin in shared restroom shower, has no tight fitting cover. To investigate the allegation LPA toured the facility at 9:27 a.m. and focused on bathrooms, occupied resident bedrooms and the kitchen. From 9:30 a.m. to 9:46 a.m while touring the faciltiy LPA interviewed two (2) out of four (4) residents and two (2) staff. In three (3) out of three (3) bathrooms LPA observed small trash bins with tight fitting lids. In two (2) out of three (3) bathrooms LPA observed a second trash bin with no lid. LPA's interview with S1 and S2 revealed they use the trash bin with no lid to collect used disposable underwear for incontinence which they take out twice a day or when needed. (Continue to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
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-20241017105841
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: AQUAMARINE RETIREMENT HOME
FACILITY NUMBER: 197606738
VISIT DATE: 10/22/2024
NARRATIVE
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(Continued from LIC9099)

S1 and S2 also revealed the other trash bin with the tight-fitting lid is used for facial tissues. In the kitchen LPA observed a bag used to collect recyclable cans and bottles, a box holding small pieces of trash, and a trash bin with a tight-fitting lid. Administrator arrived at approximately 10:45 a.m. Interview with the administrator revealed used disposable incontinence items are collected in plastic bags and thrown away outside of the facility right away after collecting. Administrator stated the bins occasionally hold the used incontinence supplies when the staff is changing a resident. The administrator immediately removed the box from the kitchen and informed LPA they would be purchasing bins with lids large enough to hold the used disposable incontinence supplies. Based on LPA's observations and interviews the allegation is deemed Substantiated at this time.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Exit interview conducted. Appeal rights provided and a copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20241017105841
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: AQUAMARINE RETIREMENT HOME
FACILITY NUMBER: 197606738
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2024
Section Cited
CCR
87303(f)(3)
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(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers... This requirement was not met as evidenced by:

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Administrator agreed to purchase 6 bins with lids to hold solid waste. A picture of the item with receipt of purchase will be sent to LPA by POC due date 11/01/2024.
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Based on LPA's observation and interviews the facility did not have tight-fitting covers on two (2) trash bins used to hold solid waste, which poses a potential health and safety 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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3