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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610126
Report Date: 09/12/2024
Date Signed: 09/12/2024 04:19:36 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
09/06/2024 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20240906091751
FACILITY NAME:LAUREL HOMEFACILITY NUMBER:
197610126
ADMINISTRATOR:ALEX ESPINOZAFACILITY TYPE:
737
ADDRESS:41447 W 25TH STREETTELEPHONE:
(661) 947-9612
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:4CENSUS: 4DATE:
09/12/2024
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:ALEX ESPINOZATIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not report incident (s) to residents' responsible party.
Staff do not have the proper training.
INVESTIGATION FINDINGS:
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On September 12, 2024, Licensing Program Analyst (LPA) Melissa Spaeth conducted an initial complaint investigation at the above facility to address the following allegation(s). LPA Spaeth met with the Administrator Alex Espinoza. LPA explained the purpose of this visit was to investigate the complaint and deliver findings.

The investigation consisted of the following: LPA and the Administrator toured the facility at 9:30 am until 9:55 am. LPA requested and reviewed the following records at 10:20 am until 11:00 am: (1) Admissions Agreement for a client (2) staff file (S1), (3) client roster; (4) staff roster; and (5) incident reports. LPA received copies of the documentation.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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-20240906091751
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAUREL HOME
FACILITY NUMBER: 197610126
VISIT DATE: 09/12/2024
NARRATIVE
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The investigation revealed the following: Regarding the allegation: Staff did not report incident (s) to residents' responsible party. It’s being alleged that restraints were used by staff on 02/02/2024, 02/27/2024, and 06/03/2024 and the incident reports were not submitted to the appropriate agencies. LPA Spaeth observed Community Care Licensing (CCL) received the LIC624 reports for the 02/02/2024 and 02/27/2024 incidents in a timely manner. LPA observed the Administrator’s copies of the report which included fax confirmations to CCL. However, LPA observed CCL did not receive the 06/03/2024 LIC624 report. The Administrator provided a copy of LIC624 dated 6/03/2024 report but the Administrator could not provide a fax confirmation.

Regarding the allegation, Staff do not have the proper training. It’s being alleged that staff member (S1) had not completed the annual sixteen hour emergency intervention training. LPA Spaeth observed S1’s training certificate dated 6/20/2023. The certificate states continued certification requires an annual re-certification. The Administrator explained there was a ninety day grace period allowed by the training company. The Administrator was under the impression there was adequate time for S1 to complete the training. Therefore, S1 did not complete the required training by 6/20/2024. The Administrator provided documentation from the training company stating S1 completed the training on 9/04/2024.

Based on interviews and record review, the allegations are substantiated. See 9099D for details.

Exit interview conducted, appeal rights discussed, and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20240906091751
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAUREL HOME
FACILITY NUMBER: 197610126
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/12/2024
Section Cited
CCR
80061(b)(1)(E)
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80061 Reporting Requirements (b) Upon the occurrence…of any of the events specified…a report shall be made to the licensing agency …In addition, a written report …shall be submitted to the licensing agency within seven days following...such event (1)...(E) Any incident... threatens,...safety of any client
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During LPA's visit, LPA Spaeth received an email confirmation stating the three incident reports were sent to residents' responsible party.
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This requirement is not met as evidenced by Based upon LPA's review of the facility fax records, staff did not report incidents to residents' responsible party. The licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
09/12/2024
Section Cited
CCR
89965(d)
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89965 Personnel Requirements (d) Direct care staff who have not completed the on-site training…shall be under the direct supervision and observation…and shall not be permitted to be alone with clients. This requirement is not met as evidenced by:
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During LPA's visit, LPA Spaeth received documentation from the training vendor stating S1 has completed the required training.
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Based upon LPA's review of staff records, S1 did not complete the annual re-certification emergency intervention training, which poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC9099 (FAS) - (06/04)
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