197610040-12-29-2021-31-AS-EMIR-CBRVF5-20220218152318

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610040
Report Date: 12/29/2021
Date Signed: 12/29/2021 02:17:02 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
12/27/2021 and conducted by Evaluator Yelena Avetisyan

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20211227091247

FACILITY NAME:	COSTA COLINA V		FACILITY NUMBER:	197610040
ADMINISTRATOR:	LIEBHARD, ELLIOTT		FACILITY TYPE:	772
ADDRESS:	2890 KANAN DUME RD		TELEPHONE:	(203) 823-8588
CITY:	MALIBU	STATE: CA	ZIP CODE:	90265
CAPACITY:	10	CENSUS: 4	DATE:	12/29/2021
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Erin Thorley Program Director		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
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9

Facility is not providing client receipt of payment for services.

INVESTIGATION FINDINGS:

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13

An unannounced initial 10 day complaint visit was conducted on this day by Licensing Program Analyst (LPA) Yelena Avetisyan. Upon arrival LPA met with Erin Thorley Program Director.

Regarding the allegation it was reported that for approximately 6 months the licensee/staff did not provide financial documents as requested for Client 1 (C1). During today's visit LPA conducted interview with the Program Director and reviewed file for Client 1 (C1). LPA requested and was provided copies of documents/emails pertinent to the investigation. Information obtained during the visit revealed the following: C1 requested treatment records via email from the Clinical Director on 7/13/2021. The records were emailed to C1 on 7/20/2021. On 11/15/2021 a request was emailed to the Program Director, however the email did not specify the additional documents requested. On 12/9/2021 a third request was sent to the Program Director and Clinical Director requesting financial records. LPA was informed that the staff are working on the request. LPA was also informed that record requests are usually completed within 30 days, Prior to this visit the LPA conducted review of the licensees plan of operation which confirms the 30 day time frame. Based on the information obtained the allegation is Unsubstantiated at this time. Exit interview conducted and copy of report emailed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021

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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