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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606869
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:34:22 PM

Unsubstantiated


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
11/04/2022 and conducted by Evaluator Melissa Ruiz
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20221104121501
FACILITY NAME:TYCOON RESIDENTIALFACILITY NUMBER:
197606869
ADMINISTRATOR:YOLANDA VILLANUEVAFACILITY TYPE:
740
ADDRESS:10204 GERALD AVENUETELEPHONE:
(818) 363-3418
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 4DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Yolanda Villanueva TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff are overmedicating resident
Staff are not providing adequate food service to resident
Staff are not meeting residents needs
INVESTIGATION FINDINGS:
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On 11/9/222, Licensing Program Analysts (LPAs) Melissa Ruiz and Joscelyn Martinez arrived at the facility to conduct an unannounced complaint investigation. Upon arrival, LPAs were greeted by the Administrator. An entrance interview was conducted, and the purpose of the visit was explained.

Allegation #1 - Staff are overmedicating resident.

To investigate this allegation, LPAs conducted a random medication count for 4 out of 4 residents, interviewed the Administrator, and interviewed 3 out of 4 residents who were able to communicate. During the random medication count conducted at 10:30 a.m., LPAs observed that each medication, which was randomly chosen for each resident, corresponded with the Centrally Stored and Destruction Logs (LIC622). Interviews conducted revealed that medication has always been given, in accordance with medication instructions and no resident or previous resident has ever been overmedicated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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-20221104121501
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: TYCOON RESIDENTIAL
FACILITY NUMBER: 197606869
VISIT DATE: 11/09/2022
NARRATIVE
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Allegation #2 - Staff are not providing adequate food service to resident.

To investigate this allegation, LPAs conducted interviews with the Administrator and 3 out of 4 residents who were able to communicate. An interview with the Administrator revealed that all residents have a minimum of three meals a day, and meals are cooked daily. 3 out of 4 residents stated they like the meals, and they eat at least three meals a day. LPAs collected a sample menu, toured the pantry and the refrigerator, and LPAs observed sufficient food.

Allegation #3 - Staff are not meeting resident’s needs.

LPAs conducted interviews with 3 out of 4 residents who were able to communicate. All three residents stated they were happy with the care they were receiving, and their needs are being met. An interview with the Administrator revealed that there was a previous resident (R1) who lived at the facility and their family voiced concern regarding their care. The Administrator stated they communicated with the family often and documented R1’s progress, such as R1’s toileting schedule, feeding schedules and change in conditions. Lastly, the Administrator stated R1’s condition improved and returned to live with their family.

Based on interviews and record review, the allegations listed above are unsubstantiated at this time. Report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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
11/04/2022 and conducted by Evaluator Melissa Ruiz
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20221104121501

FACILITY NAME:TYCOON RESIDENTIALFACILITY NUMBER:
197606869
ADMINISTRATOR:YOLANDA VILLANUEVAFACILITY TYPE:
740
ADDRESS:10204 GERALD AVENUETELEPHONE:
(818) 363-3418
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 4DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Yolanda Villanueva TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff are limiting visitors time with residents.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Melissa Ruiz and Joscelyn Martinez arrived at the facility to conduct an unannounced complaint investigation. An entrance interview was conducted, and the purpose of the visit was explained.

Allegation #4 - Staff are limiting visitors time with residents. It was alleged that staff are limiting visitors time with residents with specific time increments, such as 15- 30 minutes inside the facility. An interview with 1 out of 3 residents (R2) revealed that R2’s family is allowed to visit, only for 15 minutes if they stay inside the facility, however if they meet in the backyard, there is no time limit. LPAs reviewed resident’s admission agreements and facility visiting hours are listed from 9:00 a.m. to 9:00 p.m., no time limitations are specified. Lastly, an interview with the Administrator revealed that sometime in the lasts months, R1’s family member would visit R1 daily, bur due to R1 sharing a bedroom, the Administrator would limit visitations to 6:30 p.m. Due to interviews and record review, the allegation is deemed substantiated at this time. Deficiency issued, per CA Code of Regulations, Title 22. See LIC-9099D. Report signed and delivered.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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-20221104121501
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: TYCOON RESIDENTIAL
FACILITY NUMBER: 197606869
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2022
Section Cited
CCR
87468.1(a)(11)
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87468.1(a)(11) Personal Rights of Residents in All Facilities: To have their visitors,..., permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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A written statement shall be sent to LPA in which Administrator agreeds not to limit visitation for visitors and abide by facility's admission agreement regarding visitation shall be followed.
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This requirement is not met as evidence by: Based on interviews and record review, the administrator limited visitor's visitation time to 15-30 minutes, which poses a potential health, safety, or personal right risk.
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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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4