197609872-2-1-2023-31-AS-NGID-CPCTPX-20230224135500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609872
Report Date: 02/01/2023
Date Signed: 02/01/2023 03:59:29 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
01/26/2023 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20230126162552

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:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Erwin Estrella		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are using an inappropriate locking tool for the residents
Staff are blocking doorways to prevent residents from leaving

INVESTIGATION FINDINGS:

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

LPA Spaeth conducted an unannounced visit and was greeted by two caregivers and a resident using a walker. LPA observed both caregivers were wearing masks. LPA’s temperature was taken and recorded. LPA observed the sign in station which contained masks, sign in sheet, thermometer and hand sanitizer.

Upon entering the facility, the Caregiver asked LPA to enter the facility and Caregiver closed the front door. The Caregiver asked LPA to wait at the front door and Caregiver escorted the resident to the living room. LPA observed a portable door locking mechanism that was attached to the front door. LPA asked Caregivers what was the purpose of the portable door lock. Both caregivers stated used to make sure the door stays locked so that the resident (R1) does not open the door and leave the facility.

The Administrator arrived at 10:30 am and greeted LPA. LPA stated the purpose of the visit was to investigate a complaint which states: staff are using an inappropriate locking tool for the residents; and staff are blocking

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: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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-20230126162552

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
	VISIT DATE: 02/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

doorways to prevent residents from leaving. LPA and Administrator conducted a tour of the facility at 10:30 until 10:45 am.

The facility contained a seven-day supply of non-perishable food items and a two day supply of perishable food. The knives, resident medications, and cleaning solutions were securely locked within the facility. LPA did not observe any other safety issues.

LPA reviewed residents’ records and staff records at 11:00 am until 1130 am. LPA did not observe any issues with the records. LPA interviewed the Administrator and staff from 11:30 until 11:45 am. LPA interviewed two residents at 11:45 am until 12:00 noon. During interviews, staff and administrator stated that wheelchairs were previously used to deter residents from leaving the facility; however, LPA was informed this practice was no longer used.

Since LPA observed the portable door lock and the two caregivers and the Administrator stated the portable door lock was used to deter residents from exiting the facility, the allegations are 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

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20230126162552

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: 02/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/08/2023 Section Cited CCR 87307(d)(6)	1 2 3 4 5 6 7	87307 Personal Accomodations & Services (d)The following space and safety provisions shall apply to all facilities. (6) All outdoor & indoor passageways...shall be kept free of obstruction. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will conduct training with staff regarding care of dementia residents. Administrator will provide training content and staff sign in sheet upon completion of the training.
	8 9 10 11 12 13 14	Based on LPA's observation of the portable lock & staff/administrator interviews stating wheelchairs were previously used to block the entrance & the portable lock currently used, staff did not comply with the section cited above which poses a potential health, safety & 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: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3