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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610040
Report Date: 01/20/2022
Date Signed: 01/20/2022 12:59:57 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
12/27/2021 and conducted by Evaluator Yelena Avetisyan
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20211227091247
FACILITY NAME:COSTA COLINA VFACILITY NUMBER:
197610040
ADMINISTRATOR:LIEBHARD, ELLIOTTFACILITY TYPE:
772
ADDRESS:2890 KANAN DUME RDTELEPHONE:
(203) 823-8588
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY:10CENSUS: 4DATE:
01/20/2022
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Erin Thorley Program DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility is not providing client receipt of payment for services.


INVESTIGATION FINDINGS:
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An unannounced susbsequent complaint visit was conducted on this day by licensing program analyst (LPA) Yelena Avetisyan to deliver an amended report regarding the allegation listed above. The initial findings were issued to the licensee on 12/29/2021.

Regarding the above allegation it was reported that for approximately 6 months the licensee/staff did not provide financial documents as requested for Client 1 (C1).

During the 12/29/2021 visit LPA met with Program Director Erin Thorley who reviewed their records and provided the LPA with the following timeline/information. 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 subsequent request for records 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. During the 12/29/2021 visit LPA was informed that the staff were working on the request. LPA was also informed that record requests are usually completed within 30 days,
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
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-20211227091247
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: COSTA COLINA V
FACILITY NUMBER: 197610040
VISIT DATE: 01/20/2022
NARRATIVE
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Prior to initial visit the LPA conducted review of the licensees plan of operation which documented that they will produce requested records within 30 days.

Prior to the completion of the visit LPA requested copies of 3 emails to be forwarded to her. The 11/15/2021 and 12/9/2021 emails were forwarded to the LPA on 12/29/2021. On 12/30/2021 LPA re-requested the 7/13/2021 email to be forwarded. The email was received on 12/31/2021. LPA reviewed the email and observed that it was sent to the program Director Erin Thorley and Clinical Director Alexandra Decleene. The email was sent by C1 at which time a request was made for financial records. The email also indicated that C1 had made a prior request for financial records as well. The requested financial records were sent to C1 on 12/31/2021.
Additional information obtained revealed that C1 did not receive the requested records or receive request for other arrangements within 30 days as indicated in the licensee plan of operation therefore the Allegation finding issued on the 12/29/2021 report, is being amended from Unsubstantiated to Substantiated.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, the following deficiencies are cited (Please refer to LIC 9099-D)

Exit interview conducted. Copy of report, citations, and appeal rights were issued via email.


SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20211227091247
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: COSTA COLINA V
FACILITY NUMBER: 197610040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2022
Section Cited
CCR
81022(a)(f)
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(a )Each licensee shall have and maintain on file a current, written, definitive plan of operation. (j) The facility shall operate in accordance with the terms specified in the plan of operation and may be cited for not doing so. This requirement was not met as evidenced by.
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The requested records were provided to C1 on 12/31/2021 therefore Deficiency is cleared during the visit.
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Based on interview and records/email review the licensee did not comply with the cited section by not operating in accordance with their plan of operation and providing requested records to C1 timely which posed a potential personal rights violation to R1.
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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: Eva Miller
LICENSING EVALUATOR NAME: Yelena Avetisyan
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3