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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607345
Report Date: 05/05/2022
Date Signed: 05/05/2022 04:27:46 PM

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
05/04/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220504115139
FACILITY NAME:IVAN BANNER BOARDING CAREFACILITY NUMBER:
197607345
ADMINISTRATOR:CYNTHIA TAYLORFACILITY TYPE:
740
ADDRESS:39409 DAYLILY PLACETELEPHONE:
(661) 267-0779
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 4DATE:
05/05/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Donald FagenTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility is not following COVID-19 protocol.
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unannounced visit and was greeted by Assistant Administrator. LPA's temperature was taken and LPA was requested to sign in at the sign in station at the front door. LPA stated the purpose of the visit was to investigate a complaint which states facility is not following COVID-19 protocol. Assistant Administrator stated was confused and had heard if staff were fully vacinnated, staff would not be required to wear masks within the facility. LPA observed Assistant Administrator was not wearing a mask and LPA explained the infection control regulations regarding staff wearing masks within the facility. Assistant Administrator immdiately put mask on upon LPA's request.

LPA Spaeth toured the facility with Assitant Administrator from 11:00 am until 11:20 am. LPA observed the kitchen contained wash your hands sign, hand soap, paper towels and a trash can. LPA observed there was an adequate supply of fresh fruits and vegetables, eggs, frozen meats, and frozen vegetables in the refrigerator. LPA also observed pantry which contained pasta and canned vegetables. LPA observed the knives were locked in a kitchen drawer and there were no hazardous cleaning supplies under the kitchen sink.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
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-20220504115139
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: IVAN BANNER BOARDING CARE
FACILITY NUMBER: 197607345
VISIT DATE: 05/05/2022
NARRATIVE
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LPA observed the locked garage which contained a six month supply of PPE which included N-95 masks, face shields, gowns, gloves, and surgical masks. LPA observed the locked laundry room which contained the washer/dryer. The cleaning supplies were locked in the laundry room. LPA observed a two drawer locked cabinet in the dining room which contained the residents' medications

LPA was escorted to the second floor and LPA observed residents in rooms watching television. LPA observed the resident's beds were social distanced within each room. LPA observed the resident's bathroom which contained the wash your hands sign, soap, paper towels, and trash can.

Based upon LPA's observations, the allegation is substantiated. The deficiency is cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20220504115139
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: IVAN BANNER BOARDING CARE
FACILITY NUMBER: 197607345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2022
Section Cited
CCR
87470(5)(b)(2)
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All staff and volunteers providing direct care to a resident....shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents...This requirement was not met as evidenced by:
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LPA Spaeth observed Assistant Administrator immediately put on an N-95 mask. :PA observed Assistant Administrator placed placed a supply of masks at the sign in station.
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Upon entering the facility, LPA observed staff member was not wearing a mask which poses an immediate health and safety risk to 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.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3