197609872-9-23-2022-31-AS-CHAS-CKN2BN-20221028171524

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609872
Report Date: 09/23/2022
Date Signed: 09/23/2022 10:17:28 AM

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
09/19/2022 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20220919172357

FACILITY NAME:	ANAVERDES VILLA		FACILITY NUMBER:	197609872
ADMINISTRATOR:	ESTRELLA, ERWIN		FACILITY TYPE:	740
ADDRESS:	37335 PAINTBRUSH DR		TELEPHONE:	(661) 526-7000
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 4	DATE:	09/23/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Erwin Estrella		TIME COMPLETED:	08:44 AM

ALLEGATION(S):

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Facility staff are not wearing masks.

INVESTIGATION FINDINGS:

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LPA Spaeth conducted an unannounced visit and was greeted by staff member at the front door. LPA stated the purpose of the visit was to conduct an investigation regarding the allegation, Facility staff are not wearing masks. LPA obsered two caregivers who were assisting residents with breakfast and both were wearing a mask.

The Administrator arrived at 8:20 am and LPA observed Administrator was not wearing a mask. LPA advised Administrator to wear a mask and discussed the facility's infection control plan states all staff must wear a mask when entering the facility. The allegation therefore is substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency is cited (refer to LIC 9099-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20220919172357

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: ANAVERDES VILLA	FACILITY NUMBER: 197609872
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/28/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities(a)...(2) To be accorded safe, healthful... accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will review facility's infection control plan and will send a signed document with staff members' signature stating staff reviewed infection control plan with Administrator.
	8 9 10 11 12 13 14	Based on observations made during the 9/19/2022 complaint investigation visit the staff did not comply with the section cited above by not wearing face mask/covering while working in the facility 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: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC9099 (FAS) - (06/04)

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