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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609674
Report Date: 11/16/2022
Date Signed: 11/16/2022 04:45:29 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
08/01/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220801124440
FACILITY NAME:VERBENA CTFACILITY NUMBER:
197609674
ADMINISTRATOR:TINDLE, TRACEYFACILITY TYPE:
735
ADDRESS:37318 VERBENA CTTELEPHONE:
(661) 305-4744
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:4CENSUS: 3DATE:
11/16/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Tracey TindleTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff do not meet the required qualifications
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unnanounced visit and was greeted by the Administrator. LPA explaioned the complaint report that took place 8/04/2022 was being admended due to additional information received.

LPA discussed with Administrator the reporting party had stated within the complaint that five caregivers had not completed the required DSP 1 and DSP 2 trainings. The Administrator confirmed there were three that had not completed the DSP 1 and DPS 2 traiings. Therefore the allegation, staff do not meet the required qualifications is substantiated. Based upon LPA's observation, the following deficiency was cited. See attached 809-D for further details.

Exit interview, appeal rights discussed, and a copy of the report was given to Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
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 2
Control Number 31-AS-20220801124440
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: VERBENA CT
FACILITY NUMBER: 197609674
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2022
Section Cited
CCR
80065(f)(7)
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80065 Personnel Requirements (F) All personnel shall be given on the job training..(7) The licensee of gropu home or adult residential facility...shall meet the staff training requirements... This requirement was not met as evidenced by:
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LPA received copies of five caregivers who have received DSP 1 and DSP 2 trainings based upon the reporting party's report.
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Based upon reviewnig caregiver's training records, five caregivers did not complete the required DSP 1 and 2 trainnigs.
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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: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2