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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610126
Report Date: 04/07/2022
Date Signed: 04/11/2022 02:03:33 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
03/10/2022 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20220310101336
FACILITY NAME:LAUREL HOMEFACILITY NUMBER:
197610126
ADMINISTRATOR:STIX, ALEXANDRAFACILITY TYPE:
737
ADDRESS:41447 W 25TH STREETTELEPHONE:
(661) 947-9612
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:4CENSUS: 2DATE:
04/07/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Yolanda PickensTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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The Administrator lacks qualifications.
The administrator is not on the premises sufficient number of hours
INVESTIGATION FINDINGS:
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LPA Spaeth made an unannounced visit and was greeted by Administrator. LPA explained the purpose of the visit was to present LPA’s findings regarding the complaint which alleged administrator lacks qualifications and administrator is not on the premises a sufficient number of hours.
LPA observed two residents were working on a puzzle LPA observed all staff members were wearing a mask. LPA's temperature was taken, COVID questions answered, and LPA observed the sign in station upon entering the facility. LPA conducted a physical plant tour to ensure no immediate health and safety issues. LPA did not observe any immediate health and safety issues.

On February 15, 2022, the North Los Angeles Regional Center was made aware that the approved Administrator was not on the premises from January 12, 2022 through January 14, 2022. The Regional Center reviewed the Shift logs and discovered the Program Manager, Robert Subia had covered for the Administrator. The Regional Center reviewed the Administrator Certificate for Robert Subia and discovered the Certificate had expired. The
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
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-20220310101336
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: LAUREL HOME
FACILITY NUMBER: 197610126
VISIT DATE: 04/07/2022
NARRATIVE
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Regional Center concluded the administrator lacks qualifications and the administrator is not on the premises a sufficient number of hours. A Corrective Action plan was sent to the facilty on March 8, 2022. LPA obtained a copy of the report.

LPA interviewed the Administrator on 3/11/2022 at 2:35 pm and was informed Administrator was out due to personal circumstances. Administrator confirmed the Program Manager, Robert Subia covered for Administrator during that time. However, Program Manager’s Administrator Certificate had expired. Administrator stated there were an adequate number of staff at each shift. The North Los Angeles Regional Center informed Administrator there was no qualified administrator present at the facility a sufficient number of hours and a corrective action plan was given to the Administrator as of March 8, 2022. Administrator also informed LPA S1 is in the process of obtaining Administrator Certificate and will be the designated Administrator when Administrator is out.

Based upon the evidence received from the North Los Angeles Regional Center and Administrator’s interview, the allegations are substantiated. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).



Exit interview conducted, Appeal Rights discussed, and a copy of the report was issues to Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220310101336
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: LAUREL HOME
FACILITY NUMBER: 197610126
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2022
Section Cited
CCR
85064(a)(b)
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(a) In addition to Section 80064, the following shall apply.

(b) All adult residential facilities shall have a certified administrator.
This requirement was not met as evidenced by:
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Back up Administrator has been appointed and has been trained. Back-up Administrator is waiting for Administrator Certificate to be sent to the facility. The RSO test date will be April 11, 2022, Administrator is working the mandated 40 hours per week until the back-up Administrator receives the ARF Certification
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Based upon LPA's interviews of the Administrator and evidence received from the Complainant, the designated back-up Administrator's Certificate had expired and there was no qualified Administrator on the premises which is an immediate health & safety risk to residents in care.
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Type B
04/07/2022
Section Cited
CCR
89965(f)
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(f) Each Enhanced Behavioral Supports Home shall have an administrator on duty a minimum of 20 hours per week per facility to ensure the effective operation of the facility.
This requirement was not met as evidenced by; based on evidence received & interviews, the back-up Administrator's Certificate had
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Administrator provided Administrator Shift Log which indicates Administrator has worked the required weekly hours each month.
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expired and the back up Administrator had worked during the time the Administrator was out. Since the Back Up Administrator did not meet the Administrator qualifications, there was no qualified Administrator at the facility during the week of January 12, 2022.
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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: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC9099 (FAS) - (06/04)
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