197610126-4-11-2022-31-AS-CHAS-CDGTUH-20220414150223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610126
Report Date: 04/11/2022
Date Signed: 04/11/2022 11:10:33 AM

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
12/23/2021 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20211223105731

FACILITY NAME:	LAUREL HOME		FACILITY NUMBER:	197610126
ADMINISTRATOR:	STIX, ALEXANDRA		FACILITY TYPE:	737
ADDRESS:	41447 W 25TH STREET		TELEPHONE:	(661) 947-9612
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	4	CENSUS: 3	DATE:	04/11/2022
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Yolanda Pickens		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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9

Facility is not following the program design.

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 facility is not following the program design regarding the consultant logs. LPA observed all staff members were wearing a mask.

Complainant had stated when reviewed the resident's files, Complainant did not see consultant logs confirming R1 had received the consultant hours from outsourced services. As of today, LPA received a copy of the logs and Administrator confirmed that R1's file did contain the required logs. In regard to providing both the Administrator and staff with copies of the program design to review, Administrator confirmed this task had been completed. Therefore this allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2022

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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