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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609015
Report Date: 04/28/2025
Date Signed: 04/28/2025 05:01:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
03/06/2025 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20250306131914
FACILITY NAME:CARING HEARTS SENIOR CARE HOME LLCFACILITY NUMBER:
197609015
ADMINISTRATOR:AMORSOLO-SAMANIEGO, MARITAFACILITY TYPE:
740
ADDRESS:4144 VAHAN COURTTELEPHONE:
(661) 794-9940
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 5DATE:
04/28/2025
UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Marita Samaniego - AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not ensure facility had adequate staffing to meet resident's needs.
INVESTIGATION FINDINGS:
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On 04/28/2025 at 3:20 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived at this facility to conduct an unannounced, subsequent visit to deliver findings on the above allegations. Upon arrival, LPA met with staff and requested they contact the administrator. Staff contacted the administrator, Marita Samaniego. At approximately 3:23 p.m., LPA met with the Administrator,
LPA Rios conducted a physical plant tour to ensure the health and saftey of the residents in care. No issues observed.

To investigate the allegations LPA Rios conducted an initial visit on 3/11/2025 and obtained a copy of the resident roster, personnel report (LIC500), and staff schedule. On 3/11/2025 the administrator assistant informed LPA, one (1) resident was at the hospital and the LIC500 needed to be updated to include two new permanent staff and one on-call staff. On 3/11/2025 from approximately 11:40 a.m. to 12:20 p.m., LPA conducted interviews with three (3) out of six (6) current residents. Resident #1 (R1) is no longer in the facility. (Continue to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
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
Control Number 31-AS-20250306131914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARING HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 197609015
VISIT DATE: 04/28/2025
NARRATIVE
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(Continued from LIC9099)
The three (3) residents not interviewed were sleeping, at the hospital, or did not respond to LPA's questions. On 3/11/2025 from approximately 12:20 p.m. to 12:50 p.m., LPA conducted interviews with two (2) staff present and the assistant administrator. On 3/11/2025 from 12:50 p.m. to 1:45 LPA reviewed resident and staff records and obtained copies of residents’ Physician's Reports (LIC602A) and Appraisal / Needs and Services Plan (LIC625).

Allegation: Staff did not ensure facility had adequate staffing to meet resident's needs. Regarding the allegation, it was reported there is no overnight staff. To investigate the allegation LPA Rios conducted an initial visit on 3/11/2025. LPA's review of the facility's LIC500 revealed most shifts are from “7AM” to “7PM” with no overnight shift. The staff monthly schedule reveled two staff names on each day for this facility. The staff monthly schedule does not have which hours the staff member is covering. The assistant administrator admitted not verbatim that prior to three (3) weeks ago they did not have an overnight staff on schedule so relied on live-in staff to wake up and provide assistance when needed. Staff corroborated that there was no overnight staff assigned to provide care; however, staff would wake up if needed to assist residents with agitation, wandering, or incontinence needs. Staff interviews revealed that there is now one (1) awake staff member overnight to check on residents. LPA's review of facility's program under Basic Services states verbatim "Checks will be made on a regular basis, including night time. Patterns of incontinence will be discussed with physician. Night time, awake staff will be employed as necessary." Based on interviews and record review the allegation is deemed Substantiated.


Deficiency cited (refer to LIC9099-D). Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20250306131914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARING HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 197609015
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
87208(a)
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87208 (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation...This requirement is not met as evidenced by:
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Licensee has scheduled awake staff at night to check on residents' needs. Licensee will provide LPA an updated LIC 500, a statement of understanding regarding the regulation cited.
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Based on interviews, and record review Licensee failed to schedule an awake night staff as necessary which posed a potential health, safety or personal rights risk to persons in care.
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With the statement of understanding Licensee will include that they have reviewed facility's program regarding Basic Services and Supplemental Information to Provide Care for Persons with Dementia. POC due by 05/09/25.
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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: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
03/06/2025 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20250306131914

FACILITY NAME:CARING HEARTS SENIOR CARE HOME LLCFACILITY NUMBER:
197609015
ADMINISTRATOR:AMORSOLO-SAMANIEGO, MARITAFACILITY TYPE:
740
ADDRESS:4144 VAHAN COURTTELEPHONE:
(661) 794-9940
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 5DATE:
04/28/2025
UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Marita Samaniego - AdministratorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff left resident soiled for an extended period of time.
Staff did not respond to resident's call button in a timely manner.
INVESTIGATION FINDINGS:
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On 04/28/2025 at 3:20 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived at this facility to conduct an unannounced, subsequent visit to deliver findings on the above allegations. Upon arrival, LPA met with staff and requested they contact the administrator. Staff contacted the administrator, Marita Samaniego. At approximately 3:23 p.m., LPA met with the Administrator,
LPA Rios conducted a physical plant tour to ensure the health and saftey of the residents in care. No issues observed.

To investigate the allegations LPA Rios conducted an initial visit on 3/11/2025 and obtained a copy of the resident roster, personnel report (LIC500), and staff schedule. On 3/11/2025 the administrator assistant informed LPA, one (1) resident was at the hospital and the LIC500 needed to be updated to include two new permanent staff and one on-call staff. On 3/11/2025 from approximately 11:40 a.m. to 12:20 p.m., LPA conducted interviews with three (3) out of six (6) current residents. Resident #1 (R1) is no longer in the facility. (Continue to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20250306131914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARING HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 197609015
VISIT DATE: 04/28/2025
NARRATIVE
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(Continued from LIC9099-A) The three (3) residents not interviewed were sleeping, at the hospital, or did not respond to LPA's questions. On 3/11/2025 from approximately 12:20 p.m. to 12:50 p.m., LPA conducted interviews with two (2) staff present and the assistant administrator. On 3/11/2025 from 12:50 p.m. to 1:45 LPA reviewed resident and staff records and obtained copies of residents’ Physician's Reports (LIC602A) and Appraisal / Needs and Services Plan (LIC625).

Allegation: Staff left resident soiled for an extended period of time.
Allegation: Staff did not respond to resident's call button in a timely manner.

Regarding the allegations, it was reported that Resident #1 (R1) requested toileting assistance around 3:00 a.m. but did not receive timely attention, resulting in being left in soiled undergarments. LPA's interview with the assistant administrator revealed that a complaint had been received by the facility a few weeks ago from a resident's family member about how staff treated the resident. According to the assistant administrator, Staff #1 (S1) and Staff #2 (S2) were let go as a precaution based on the statements made by the family. LPA's review of residents’ LIC602 and LIC625 revealed resident have bowel and bladder impairment. LPAs interview with staff on 3/11/2025, corroborates all current residents require incontinence care. The assistant administrator admitted not verbatim that prior to three (3) weeks ago they did not have an overnight staff on schedule so relied on live-in staff to wake up and provide assistance when needed. Staff corroborated that there was no overnight staff assigned to provide care; however, staff would wake up if needed to assist residents with agitation, wandering, or incontinence needs. Staff interviews revealed that there is now one (1) awake staff member overnight to check on residents. LPAs interview with staff on 3/11/2025 deny witnessing residents in soiled diapers from the previous shift or not attending to residents timely except for when they were assisting another resident in which case they would excuse themselves to check on the resident that was calling for assistance. LPA's interview with three (3) current residents revealed that wait times do vary not specific to the time of day but that they have no concerns about the wait time. Based on interviews and record review the allegations are unsubstantiated.
Exit Interview. Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5