197609758-5-12-2022-31-AS-RRAZ-CKGRZH-20221023132755

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609758
Report Date: 05/12/2022
Date Signed: 05/12/2022 06:03:05 PM

Unsubstantiated

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
01/12/2022 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20220112143232

FACILITY NAME:	DANIAS SENIOR HOME		FACILITY NUMBER:	197609758
ADMINISTRATOR:	BAEZA, DANIA ELISABETH		FACILITY TYPE:	740
ADDRESS:	22331 COVELLO ST		TELEPHONE:	(747) 226-3342
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91303
CAPACITY:	6	CENSUS:	DATE:	05/12/2022
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:			TIME COMPLETED:	06:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was unkempt

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At approximately 5:30 p.m. on 05/12/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with Administrator and disclosed the reason for the visit.

Regarding the allegation “Resident was unkempt”, it was alleged Resident #1 (R1) was in poor condition due to being unchanged. To investigate the allegation, LPA conducted a physical plant tour and interviews. At approximately 12:15 p.m. LPA observed R1 in their room. R1 was sitting in a wheelchair and in good condition. LPA conducted interviews with complainant on 01/12/2022 at 4:08 p.m. and with facility staff on 01/20/2022 at 12:40 p.m. Based on interviews, there is not sufficient evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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
01/12/2022 and conducted by Evaluator Nicholas Reed

COMPLAINT CONTROL NUMBER: 31-AS-20220112143232

FACILITY NAME:	DANIAS SENIOR HOME		FACILITY NUMBER:	197609758
ADMINISTRATOR:	BAEZA, DANIA ELISABETH		FACILITY TYPE:	740
ADDRESS:	22331 COVELLO ST		TELEPHONE:	(747) 226-3342
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91303
CAPACITY:	6	CENSUS: 4	DATE:	05/12/2022
		ANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Marisol		TIME COMPLETED:	05:27 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident was triple diapered

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At approximately 5:30 p.m. on 05/12/2022 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with Administrator and disclosed the reason for the visit.

Regarding the allegation “Resident was triple diapered”, it was alleged staff put new diapers over old, soiled diapers. To investigate the allegation, LPA conducted a physical plant tour and interviews. At approximately 12:15 p.m. on 01/20/2022 LPA observed R1 in their room. R1 was in good condition and wearing a single diaper. At 12:40 p.m. on 01/20/2022 LPA interviewed staff. Based on 2 out of 3 interviews, staff confirmed a former employee had double diapered R1. Administrator fired the staff upon learning of the event. Based on LPA's observations and interviews, the preponderance of evidence standard has been met. The above allegation is therefore deemed to be SUBSTANTIATED at this time. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099-D.

Exit interview conducted. Copy of report and appeal rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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-20220112143232

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: DANIAS SENIOR HOME	FACILITY NUMBER: 197609758
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/10/2022 Section Cited CCR 87625(b)(1)	1 2 3 4 5 6 7	87625 Managed Incontinence (b the licensee shall be responsible for the following: (1) Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will provide in-service training for all staff on the cited section and submit proof to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above in 1 out of 5 residents which poses a potential Health, Safety, and Personal Rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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