197608294-5-10-2021-31-AS-CHAS-C4EP43-20210628105828

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608294
Report Date: 05/10/2021
Date Signed: 05/10/2021 11:38:58 AM

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
05/06/2021 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20210506154813

FACILITY NAME:	J.R. RETIREMENT HOME FOR ELDERLY		FACILITY NUMBER:	197608294
ADMINISTRATOR:	JEFFERSON L. REYES		FACILITY TYPE:	740
ADDRESS:	44035 22ND STREET WEST		TELEPHONE:	(661) 951-0994
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	05/10/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Roger Remoroso		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff barricaded the entry door of the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith conducted an initial complaint visit to this facility to investigate the allegation above. LPA met with facility staff and explained the reason for this visit. Administrator was notified and made aware of this visit.

Regarding the allegation above it is alleged that on 5/3/21 the entry door of the facility was barricaded by having a couch placed in front of it. LPA conducted an interview with facility staff who admitted to doing this because they had a resident who wandered. During today's visit LPA did not observe the front door to be barricaded. Based on the information obtained through interviews this allegation is deemed Substantiated. Facility staff admitted that the entry door was barricaded with couch due to a resident wandering. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

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-20210506154813

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: J.R. RETIREMENT HOME FOR ELDERLY	FACILITY NUMBER: 197608294
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/12/2021 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	Personal Rights- To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator shall submit plan on proper supervision for residents who have a tendency to wander and how they will be properly supervised.
	8 9 10 11 12 13 14	Based on information obtained through interviews facility staff baracaded the front door with a couch due to resident wandering. This posed a health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

LIC9099 (FAS) - (06/04)

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