197607261-6-28-2022-31-AS-MVAO-CFV2EA-20220629171936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607261
Report Date: 06/28/2022
Date Signed: 06/28/2022 07:08:09 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
08/25/2020 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20200825120413

FACILITY NAME:	CANYON VIEW RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	197607261
ADMINISTRATOR:	MARICAR SERRANO		FACILITY TYPE:	740
ADDRESS:	26881 CUATRO MILPAS STREET		TELEPHONE:	(661) 513-9039
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91354
CAPACITY:	0	CENSUS:	DATE:	06/28/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Maricar Serrano, Ronald Tolentino		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility staff failed to seek medical attention for resident in a timely manner.
Facility staff failed to follow doctor's orders.
Staff restraining resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to conclude the investigation regarding the above allegations. The 10 day visit was made by LPA Arambulo on 9/20/20. Note that this facility closed on 12/4/20 under change in ownership, but LPA was able to interview the administrator of the closed facility, Maricar Serrano, who is also the current adminstrator under the new license, facility #197610079. During the course of the investigation, interviews with the facility administrator, staff and residents were made, and record review was conducted.

Facility staff failed to seek medical attention for resident in a timely manner/Facility staff failed to follow doctor's orders:
In regards to the allegations, on or around 8/13/20, it was reported that Resident 1 (R1) was experiencing episodes of confusion and needed a urine culture. When the home health agency was ordered to obtain the urine culture, R1 was uncooperative. The home health doctor ordered for the licensee to send R1 to the

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20200825120413

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: CANYON VIEW RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 197607261
	VISIT DATE: 06/28/2022

NARRATIVE

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hospital, but it was alleged that the licensee refused and stated they would "forcefully" collect the urine culture. Information received through interviews reveal that R1 was sent to the hospital for treatment and medical attention when R1 did not cooperate with the urine sample. The administrator confirmed this, and adds that R1's primary physician was contacted, and they ordered R1 a new home health agency for treatment. Facility had no further complications with the new home health agency after. They have since ended their service. Since the change in ownership, R1 has continued to stay at the same facility that is under the new ownership (facility #197610079). Furthermore, R1's family expressed no complaints or concern regarding the care and supervision provided. Based on the information obtained, there is insufficient evidence to prove the allegation of staff failing to seek medical attention and staff failing to follow doctor's orders. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff restraining resident:
In regards to the allegation, it was alleged that staff would "forcefully" collect R1's urine culture. Interview with the administrator indicates that facility staff would never restrain a resident, or forcefully make them do something they do not want to do. Interviews with residents and staff could not confirm the allegation. Witnesses, date and time were also not identified to confirm the allegation. Based on the information obtained, there is insufficient evidence to prove the allegation of staff restraining residents. Therefore, the allegation is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC9099 (FAS) - (06/04)

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