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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606773
Report Date: 09/26/2022
Date Signed: 09/26/2022 11:47:02 AM

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
09/19/2022 and conducted by Evaluator Joscelyn Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220919202333
FACILITY NAME:BEST ELDER CARE IIIFACILITY NUMBER:
197606773
ADMINISTRATOR:FABIOLA IGIDFACILITY TYPE:
740
ADDRESS:38648 CORTINA WAYTELEPHONE:
(661) 274-2413
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:6CENSUS: 6DATE:
09/26/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Vincent Igid TIME COMPLETED:
11:55 AM
ALLEGATION(S):
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Facility staff are not adhering to COVID-19 Protocols.
INVESTIGATION FINDINGS:
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On 09/26/22 Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced complaint investigation. Upon arrival LPA met with staff and the purpose of the visit was explained.

Upon arrival LPA observed S1 wearing a mask. S1 screened LPA and took LPA's temperature. S2 was also observed wearing a mask.

At 11:10 a.m LPA conducted a tour of the facility to ensure no immediate health and safety issues were present. S2 contacted administrator and LPA discussed the purpose of the visit with administrator.

Allegation #1 Facility staff are not adhering to COVID-19 Protocols.

It is alleged on 07/27/22 a credible witness visited the facility. During this visit, the credible witness was not screened upon entry and observed a staff not wearing their masks.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
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-20220919202333
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: BEST ELDER CARE III
FACILITY NUMBER: 197606773
VISIT DATE: 09/26/2022
NARRATIVE
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Interview with the Administrator confirmed that sometime, around July 2022, a random visit was made by a credible witness who observed facility staff were not wearing masks and not screened upon entry. Administrator admitted that a verbal conversation with the credible witness took place in regards to these observations. Based on interview with administrator this allegation is deemed Substantiated. Administrator was not able to sign the report and designated staff to sign on their behalf.


Deficiencies were issued per CA code of Regulations Title 22 on LIC9099-D with this report. Appeal rights issued. Report signed and delivered. Exit interview conducted.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20220919202333
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: BEST ELDER CARE III
FACILITY NUMBER: 197606773
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2022
Section Cited
CCR
87470(c)(1)(f)
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87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and...

This requirement is not met as evidenced by:
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Licensee/Administrator agreed to provide in house training with all staff regarding Infection Control Requirements and COVID Protocol. A written statement signed by all staff regarding such training shall be emailed to LPA no later than 10/03/22.
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Based on an interview with the Administrator, the licensee/administrator stated that during a previous visit conducted by the credible witness, staff did not comply with the section cited above by not wearing masks nor screening for covid-19 which poses a potential Health and 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: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3