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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609715
Report Date: 10/06/2022
Date Signed: 10/06/2022 12:01:14 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
09/27/2022 and conducted by Evaluator Melissa Ruiz
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220927181551
FACILITY NAME:HEAVENLY HOME CAREFACILITY NUMBER:
197609715
ADMINISTRATOR:ASSEFA, YAYINEABEBAFACILITY TYPE:
740
ADDRESS:44812 RUTHRON STTELEPHONE:
(703) 589-4408
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 2DATE:
10/06/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mekdelawit JohnsonTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Staff did not follow Covid-19 safety protocols.
INVESTIGATION FINDINGS:
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On 10/6/2022 Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced complaint investigation. Upon arrival, LPA was greeted by staff (S1) and S1 was observed to not be wearing a mask. S1 contacted the Administrator, who was unavailable, due to a family emergency. Administrator designated S1 to sign this report. At 11:25 a.m., LPA conducted a tour of the facility to ensure no immediate health and safety issues were present.
Allegation: Staff did not follow covid-19 safety protocols.
It is alleged that on 4/4/22, a credible witness visited the facility. During this visit, the credible witness was greeted by a staff member who did not screen the visitor for covid-19 symptoms. LPA interviewed the Administrator, to which she confirmed that sometime around April 2022, a random visit was conducted by the credible witness and a conversation with the credible witness took place regarding these observations. Based on the interview with administrator and LPA’s observation, this allegation is deemed Substantiated. Deficiencies issued per CA code of Regulations Title 22. Appeal rights issued. Report signed and delivered. Exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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
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
09/27/2022 and conducted by Evaluator Melissa Ruiz
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220927181551

FACILITY NAME:HEAVENLY HOME CAREFACILITY NUMBER:
197609715
ADMINISTRATOR:ASSEFA, YAYINEABEBAFACILITY TYPE:
740
ADDRESS:44812 RUTHRON STTELEPHONE:
(703) 589-4408
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 2DATE:
10/06/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mekaeliit JohnsonTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Staff did not respond to LTCO's requests for communication in a timely manner.
INVESTIGATION FINDINGS:
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On 10/6/2022 Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced complaint investigation.

Allegation: Staff did not respond to LTCO's requests for communication in a timely manner.

LPA interviewed the Administrator to which she stated that given the events that occurred in April 2022, she spoke with LTCO verbally over the phone the next day after their visit. Administrator stated they spoke about covid-19 safety protocols such as ensuring staff wear masks and visitors sign in. Administrator stated that to her knowledge, LTCO has not tried to contact her any time after that.

Due to interviews conducted, there is insufficient evidence to prove this allegation may or may not have happened. Therefore, this allegation is unsubstantiated at this time. Exit interview conducted, report signed and delivered.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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 3
Control Number 31-AS-20220927181551
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: HEAVENLY HOME CARE
FACILITY NUMBER: 197609715
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2022
Section Cited
CCR
87470(c)(1)(F)
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87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and..

This requirement is not met as evidenced by:
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Administrator agreed to provide in house training with all staff regarding Infection Control Requirements and COVID Protocol. A written statement signed by all staff regarding such training shall be emailed to LPA no later than 10/8/22
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Based on an interview with the Administrator and observation, staff did not comply with the section cited above by not wearing masks nor screening for covid-19 which poses a potential Health and Safety and personal rights risk to persons 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3