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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610009
Report Date: 02/18/2023
Date Signed: 05/19/2023 07:30:38 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2023 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20230216084959
FACILITY NAME:TEESDALE VILLA RCFEFACILITY NUMBER:
197610009
ADMINISTRATOR:GUEVARRA, CORAZON HALILIFACILITY TYPE:
740
ADDRESS:7663 TEESDALE AVENUETELEPHONE:
(818) 356-5152
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 3DATE:
02/18/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Corazon GuevarraTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Staff left residents unsupervised for an extended period of time.
INVESTIGATION FINDINGS:
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This is an amended report. Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to gather signatures for the amended report. The LPA inadvertently used the incorrect regulation to site the facility. The correct regulation has been added to the Deficiency page.Licensing program Analyst (LPA), Sandra Urena conducted an unannounced visit to investigate the allegation listed above. The LPA arrived at the facility at 11:15 a.m. and met with the Administrator, and explained the reason for the visit.On 02/16/2023, the LPA and the conducted an interview with the administrator from 12:00 p.m. to 12:15 p.m.
On the allegation that ‘Staff left residents unsupervised for an extended period of time’; the complainant’s concern is that S1 left residents unattended for an unspecified amount of time, and leaving residents unattended for any amount of time is a safety hazard. To investigate the allegation, LPA Urena interviewed the administrator and the interview revealed that the staff #1(S1) denied not being away, that they were in the back of the facility. However, the administrator cannot confirm whether S1 was at the facility, or not during the visit of an outside agency.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2023
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 29-AS-20230216084959
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: TEESDALE VILLA RCFE
FACILITY NUMBER: 197610009
VISIT DATE: 02/18/2023
NARRATIVE
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Based on the interviews, there is sufficient evidence to support the claim that Staff left residents unsupervised for an extended period of time. Therefore, the allegation, is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D).

Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were reviewed and issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230216084959
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TEESDALE VILLA RCFE
FACILITY NUMBER: 197610009
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/27/2023
Section Cited
CCR
87464(f)(87464(f)(1)
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 87464(f)(1) Basic Services.(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). The requirement was not met as evidenced by:
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The licensee shall develop a plan to ensure that staff are always present to supervise residents, and provide training on this plan to all staff by February 24, 2023. Submit the plan to CCL by February 27, 2023.
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Based on interviews and a credible witness, residents were left unsupervised on 02/14/2023, which posed an immediate health and safety 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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3