197610169-4-26-2023-31-AS-EMIR-CTUMUY-20230718095553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610169
Report Date: 04/26/2023
Date Signed: 04/26/2023 12:30:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
04/20/2023 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20230420101024

FACILITY NAME:	BEYOND A HOME LLC		FACILITY NUMBER:	197610169
ADMINISTRATOR:	RICHARDSON, KESHA		FACILITY TYPE:	740
ADDRESS:	6023 WEST AVE L 12		TELEPHONE:	(661) 860-5048
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 2	DATE:	04/26/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Sandy Iraheta		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff did not follow special diet for resident.

INVESTIGATION FINDINGS:

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At 10:15 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced initial complaint visit at the facility mentioned above. LPA was greeted by caregiver Sandy Iraheta. Sandy called the Administrator Kesha Richardson and LPA informed the Administrator the purpose of the visit and an entrance interview was conducted with Administrator over the phone. Administrator could not meet LPA at the facility and designated caregiver Sandy to sign this report.

At approximately 10:30 a.m., LPA and Sandy conducted a physical plant tour to insure the health and safety of the residents in care. LPA did not observed any health and safety issues or concerns. While conducting the tour LPA interviewed Sandy. At 10:50 a.m. LPA reviewed and collected documents relevant to this investigation. At 11:32 a.m. LPA interviewed two (2) out of the two (2) residents present. At 11:47 a.m. LPA contacted the Administrator with follow-up questions.

(Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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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Control Number 31-AS-20230420101024

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BEYOND A HOME LLC	FACILITY NUMBER: 197610169
	VISIT DATE: 04/26/2023

NARRATIVE

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Allegation: Staff did not follow special diet for resident.
It is alleged on 12/24/22, resident #1 (R1) was observed eating ice cream and pie given by staff although it is believed R1 had a special diet order not to have sugar in their meals. To investigate this allegation LPA interviewed the Administrator, the caregiver and residents present. LPA also reviewed and obtained relevant documentation. Interviews revealed all residents are provided low sodium meals and special diets are followed as per doctor orders. Records revealed R1 had no special diet order on sugar intake. Based on interviews and file reviews this allegation is Unsubstantiated at this time.

No deficiencies issued at this time. Report signed and delivered. Exit interview conducted.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

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