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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609488
Report Date: 06/22/2022
Date Signed: 06/22/2022 02:17:33 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
06/15/2022 and conducted by Evaluator Melissa Ruiz
COMPLAINT CONTROL NUMBER: 31-AS-20220615142553
FACILITY NAME:LIVELY HOME CAREFACILITY NUMBER:
197609488
ADMINISTRATOR:TOPACIO, MARFIEBETHFACILITY TYPE:
740
ADDRESS:44328 LIVELY AVETELEPHONE:
(661) 945-5376
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 5DATE:
06/22/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marfiebeth TopacioTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff yelled at resident in care.
INVESTIGATION FINDINGS:
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At 12:30 p.m., Licensing Program Analysts Melissa Ruiz and Joscelyn Martinez arrived at this facility to conduct an unannounced complaint investigation. Upon arrival, LPAs were greeted by staff and granted access to the home. LPAs later met with the Administrator, Marfiebeth Topacio explained the purpose of the visit.

Allegation: Staff yelled at resident in care.

To investigate this allegation, LPAs conducted interviews with two (2) staff, the Administrator and five (5) residents. During the interview conducted with staff (S1), admitted raising their voice and yell at residents in care. The Administrator, staff (S2) and one out of five residents (R1) stated they have witnessed S1 yell at residents in care. Based on interviews conducted, this allegation is substantiated at this time.

Deficiencies were issued per CA code of Regulations Title 22. See 9099D's included with this report. Appeal rights issued. Report signed and delivered. Exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
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-20220615142553
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: LIVELY HOME CARE
FACILITY NUMBER: 197609488
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2022
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1) Personal Rights of Residents in All Facilities (a) Residents in all residential care faciltiies for the elderly shall have all of the following personal rights.(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidenced by:
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Administrator has initiated personal rights training for all staff. A written statement acknowledging training will be submitted for each staff by the POC due date.
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Based on interviews conducted with the Administrator and staff, the licensee did not comply with the section cited above in which a staff yelled at a resident in care. This poses a potential health, and safety or personal rights 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.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
06/15/2022 and conducted by Evaluator Melissa Ruiz
COMPLAINT CONTROL NUMBER: 31-AS-20220615142553

FACILITY NAME:LIVELY HOME CAREFACILITY NUMBER:
197609488
ADMINISTRATOR:TOPACIO, MARFIEBETHFACILITY TYPE:
740
ADDRESS:44328 LIVELY AVETELEPHONE:
(661) 945-5376
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 5DATE:
06/22/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marfiebeth TopacioTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Allegation: Staff hit resident in care.
Allegation: Staff caused injuries to resident in care.
INVESTIGATION FINDINGS:
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At 12:30 p.m., Licensing Program Analysts Melissa Ruiz and Joscelyn Martinez arrived at this facility to conduct an unannounced complaint investigation. Upon arrival, LPAs were greeted by staff and granted access to the home. LPAs later met with the Administrator, Marfiebeth Topacio explained the purpose of the visit. To investigate these allegations, LPAs conducted interviews with the Administrator, two (2) staff, and five (5) residents from 1:00 – 1:45 p.m.The Administrator stated they have never witnessed a staff hit any resident in care. The Administrator stated there was an incident that occurred on June 13, 2022 where the Administrator was told by a witness that they saw a staff (S1) hit a resident (R1) and that resident had a red mark on their body. The Administrator advised another staff member (S2) inspect R1, but S2 did not observe any injuries or marks. In addition, S2 stated they have never witnessed S1 hit or cause injury to a resident in care. S2 corroborated that on June 13, 2022, they were instructed by the Administrator to check R1 for any marks or injuries and did not observe any. Lastly, LPAs attempted to conduct interviews with five (5) residents in care, all of which have never witnessed a staff hit a resident in care or a staff cause injuries to a resident in care. Based on interviews conducted, these allegations are unsubstantiated at this time. An exit interview was conducted with the Administrator. The report was signed and delivered.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3