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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607284
Report Date: 09/03/2021
Date Signed: 09/03/2021 02:12:45 PM



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
09/01/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210901154216
FACILITY NAME:LIFESTYLE HOME CARE FOR SENIORSFACILITY NUMBER:
197607284
ADMINISTRATOR:BIENVENIDA B. GOUDEAUXFACILITY TYPE:
740
ADDRESS:11734 DORAL AVENUETELEPHONE:
(818) 368-5108
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY:4CENSUS: 2DATE:
09/03/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Bienvenida GoudeauxTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff is not providing adequate supervision of the residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced initial complaint visit. LPA met with the administrator and explained the reason for this visit.
Upon entry to the facility LPA conducted a physical plant tour to ensure no immediate health and safety issues were present. LPA did not observe any immediate health and safety issues.
Regarding the allegation above it is alleged that on 8/12/21 a visit was made by the Long Term Care Ombudsman(LTCO) and when they came the residents were present in the facility and were unsupervised. The administrator was in their room and had fallen asleep which left the residents unsupervised. LPA conducted an interview with the administrator regarding the allegation. Administrator admitted that they had fallen asleep for a short period of time but that there was another staff present who did not speak to the LTCO due to not knowing who they were. Based on the information obtained through interviews this allegation is deemed Substantiated. Residents were unsupervised that the staff that was present did not identify themselve as staff. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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 2
Control Number 31-AS-20210901154216
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: LIFESTYLE HOME CARE FOR SENIORS
FACILITY NUMBER: 197607284
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2021
Section Cited
CCR
8464(f)(c)
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Basic Services-Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by:
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Administrator stated that an updated staff schedule would be sent to LPA detailing who is on shift during all hours of the day. A signed statement that residents will always have proper supervision will be sent to LPA by poc due date.
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Based on interviews conducted on 8/12/21 residents were not provided care and supervision for a period of time due to the administrator falling asleep which posed an immediate health and safety risk to the residents 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: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC9099 (FAS) - (06/04)
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