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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610101
Report Date: 07/20/2021
Date Signed: 07/20/2021 12:24:38 PM



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
07/15/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210715154306
FACILITY NAME:HAMLIN ELDER CAREFACILITY NUMBER:
197610101
ADMINISTRATOR:BIGORNIA, LIMA ROSEFACILITY TYPE:
740
ADDRESS:20300 HAMLIN ST.TELEPHONE:
(818) 912-6289
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:6CENSUS: 3DATE:
07/20/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lima Rose BigorniaTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
Resident was left unattened on the floor for extended period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to this facility. LPA met with the administrator and explained the reason for this visit.
Upon entry to the facility LPA conducted a physical plant tour to ensure no health and safety issues and compliance with Title 22 regulations. No health and safety issues were noted during the visit.
Regarding the allegation it is alleged that resident # 1 (R1) had a fall and was unattended on the floor for an extended period of time. At approximately 10:00 am LPA conducted interviews with facility staff and R2 who is R1's roommate. LPA was unable to interview R1 due to their medical diagnosis. At approximately 10:25 am LPA conducted an interview with the administrator. Information from interviews revealed that on 7/15/21 R1 sustained a fall from their bed. The fall happened approximately between 1:00am -1:15 am. R1 was not assisted off of the floor until approximately after 3:00 am. R2 stated they attempted to get staff's attention by yelling and by telephone was unable to get staff's attention.n At approximately 10:45 am LPA reviewed R1's facility file. Based on the information obtained through interviews this allegation is deemed Substantiated at this time. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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-20210715154306
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: HAMLIN ELDER CARE
FACILITY NUMBER: 197610101
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All facilities-To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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7
Administrator stated she will have an in-service with staff regarding night supervision. A staff schedule detailing night coverage will be sent to LPA.
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Based on information obtained through interviews R1 had a fall from their bed and was on the floor for a long period of time which posed an immediate health and safety issue to residents in care.
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Type A
07/21/2021
Section Cited
CCR
87464(f)(1)
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Basic Services-Basic services shall at a minimum include care and supervision. This requirement was not met as evidenced by:
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Administrator stated she will have an in-service with staff regarding night supervision. A staff schedule detailing night coverage will be sent to LPA.
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Based on interviews conducted R1 was left unattended on the floor for a long period of time after falling out of bed.
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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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2