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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610101
Report Date: 08/03/2022
Date Signed: 08/03/2022 12:28:40 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
02/01/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220201103420
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: 2DATE:
08/03/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Delfin BilledoTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Insufficient staff to meet residents' needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to investigate the allegation above. LPA met with facility staff and explained the reason for this visit. LPA spoke with the administrator by telephone and explained the reason for this visit.
LPA conducted a physical plant tour from 9:30-9:45am to ensure no immediate health and safety issues. No issues were noted.
Regarding the allegation above it is alleged that there is no staff assistance from 9pm to 6am at the night time. The initial visit was conducted by LPA Spaeth on 2/3/22. Interviews were conducted with the administrator and facility staff during the initial visit. Interviews revealed that residents that need assistance during the night were checked on at 9pm and then at 12 am, and then again around 5 am. Interview with administrator revealed that staff sleeps in the living room on a cot and when a resident needs anything the staff assist. Based on the information obtained through interviews this allegation is deemed Substantiated at this time. There was a resident # 2(R2) who required to be turned every two hours and based on what the staff stated that was not happening.
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: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
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 4
Control Number 31-AS-20220201103420
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
VISIT DATE: 08/03/2022
NARRATIVE
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Interview with administrator showed that staff sleeps in a common area during the night and there is not awake staff available. Deficiencies cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted. Copy of report issued.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220201103420
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: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2022
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 facility staff was not providing supervision during the hours of 9pm through 6 am according to resident's needs which poses an immediate health and safety risk to residents in care.
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Type A
08/05/2022
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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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 R2 was not being turned every two hours and they should have been 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.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4