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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608857
Report Date: 11/12/2021
Date Signed: 11/12/2021 02:46:00 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
06/21/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20210621155044
FACILITY NAME:SARA'S HOME AWAY FROM HOMEFACILITY NUMBER:
197608857
ADMINISTRATOR:DANIEL D. CHOFACILITY TYPE:
740
ADDRESS:23820 VIA JACARATELEPHONE:
(661) 388-4464
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 3DATE:
11/12/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rommel Catajay - StaffTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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9
Staff is leaving residents unattended while in care
INVESTIGATION FINDINGS:
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This is an amendment of the report issued on 09/30/21 to change the findings.

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegation. LPA met with staff Dulce Catajay and explained the reason for the visit.

LPA conducted physical plant tour at 9:15 AM. Requested and reviewed facility documents relevant to the investigation at 9:45 AM and interviewed staff at 10:15 AM. Regarding the allegation that Staff is leaving residents unattended while in care, It was alleged that upon Credible Witness (CW)'s entrance at the facility on 06/07/21, no staff was present with the residents. LPA's interview with staff on 06/24/21 at 10:00 AM and today at 10:15 AM, revealed that S1 was at the garage when CW came but was coming in and out to periodically check the residents while Staff #2 (S2) was running an errand. (continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
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 5
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
06/21/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20210621155044

FACILITY NAME:SARA'S HOME AWAY FROM HOMEFACILITY NUMBER:
197608857
ADMINISTRATOR:DANIEL D. CHOFACILITY TYPE:
740
ADDRESS:23820 VIA JACARATELEPHONE:
(661) 388-4464
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: DATE:
11/12/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rommel Catajay - StaffTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is not following proper Covid-19 protocols
INVESTIGATION FINDINGS:
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5
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7
8
9
10
11
12
13
This is an amendment of the report issued on 09/30/21. No changes on the findings.

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to this facility to further investigate the above allegation. LPA met with staff Dulce Catajay and explained the reason for the visit.

LPA conducted physical plant tour at 9:15 AM. Requested and reviewed facility documents relevant to the investigation at 9:45 AM and interviewed staff at 10:15 AM. Regarding the allegation that Staff is not following proper Covid-19 protocols, it was alleged that staff did not screen the Credible Witness (CW) upon entrance and not wearing mask. LPA's observation during the initial visit on 06/24/21 at 8:59 AM and today's visit at 9:15 AM, revealed that staff are wearing mask and took LPA's temperature upon entry. During CW's visit on 06/07/21 however, CW observed that Staff #1 (S1) was not wearing mask. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20210621155044
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: SARA'S HOME AWAY FROM HOME
FACILITY NUMBER: 197608857
VISIT DATE: 11/12/2021
NARRATIVE
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(continued from LIC 9099-A)

LPA's interview with S1 today at 11:00 AM, revealed that R1 was not wearing mask only because S1 was at the garage computer alone and looking for staff training. Further, R1 denied refusing to wear mask and was not able to take CW's temperature as the CW let self in into the house before S1 got into the house from the attached garage and found CW already talking to a resident.

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at the this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20210621155044
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: SARA'S HOME AWAY FROM HOME
FACILITY NUMBER: 197608857
VISIT DATE: 11/12/2021
NARRATIVE
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(continued from LIC 9099-C)

LPA's interview with Staff #2 (S2) on 06/24/21 at 10:22 AM, also revealed that S2 ran a quick errand to buy some grocery for dinner and only took only about fifteen (15) to twenty (20) minutes because the grocery store is just nearby.

Based on the information gathered during this and prior visit, the allegation is deemed substantiated at this time.
Citation issued. Appeal rights discussed and given.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20210621155044
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: SARA'S HOME AWAY FROM HOME
FACILITY NUMBER: 197608857
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/15/2021
Section Cited
CCR
87413(a)(1)
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When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.

This requirement is not met as evidenced by:
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Administrator agreed to submit a statement of understanding the regulation cited and ensure that there is adequate coverage when a staff is absent at the facility and submit to CCL on or before the POC date.
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Based on CW's observation, there was not staff present nearby resident when CW arrived. Licensee did not ensure that there is a staff present when another staff left the facility. This poses a potential health and safety risk to the resident 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: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5