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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609968
Report Date: 03/14/2023
Date Signed: 03/14/2023 04:55:33 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
03/07/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20230307142411
FACILITY NAME:AFFECTIONATE CARE HOMEFACILITY NUMBER:
197609968
ADMINISTRATOR:GUZMAN, LIBRADO DEFACILITY TYPE:
740
ADDRESS:23241 VIA CALISEROTELEPHONE:
(661) 607-9624
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 5DATE:
03/14/2023
UNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Librado De GuzmanTIME COMPLETED:
05:04 PM
ALLEGATION(S):
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Facility staff are not following proper COVID-19 mask guidance.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA met with, the administrator, Librado De Guzman and explained the reason for the visit.

--- Facility staff are not following proper COVID-19 mask guidance.
It was alleged that staff are not wearing masks while in the facility. To investigate this allegation, on 03/14/2023, LPA made observations during a physical plant tour at 3:00 PM and interviewed two (02) staff from 03:45 PM – 4:15 PM. Upon entry, LPA observed that all staff were not wearing masks. During the interviews, staff admitted to not following infection control protocols. Based on observations and interviews, the allegations are SUBSTANTIATED at this time.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):
No health and safety hazards noted during the visit. Exit interview was conducted and a copy of report was issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
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 2
Control Number 31-AS-20230307142411
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: AFFECTIONATE CARE HOME
FACILITY NUMBER: 197609968
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/16/2023
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 as evidenced by safe and effective job performance. This requirement is not met as evidenced by;
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87470 Infection Control Requirements; The written letter must be sent to the LPA by the POC due date.
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Based on observations and interviews, the licensee did not ensure that staff are wearing mask at all times while at the facility and that all visitors are screened upon entry which poses an immediate health, safety and personal rights risk to residents 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: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023
LIC9099 (FAS) - (06/04)
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