197610178-10-9-2023-31-AS-MVAO-CWSPHR-20231020112022

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610178
Report Date: 10/09/2023
Date Signed: 10/09/2023 11:32:46 AM

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
07/18/2023 and conducted by Evaluator Evelin Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230718160426

FACILITY NAME:	ANNIKA GRACE CARE HOME		FACILITY NUMBER:	197610178
ADMINISTRATOR:	BATUIAN, JOZAM LATAYAN		FACILITY TYPE:	740
ADDRESS:	6338 W AVENUE J11		TELEPHONE:	(818) 802-8004
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 2	DATE:	10/09/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Jozam Batuian		TIME COMPLETED:	11:32 AM

ALLEGATION(S):

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Facility staff did not provide records to resident's authorized representative.

INVESTIGATION FINDINGS:

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On 10/09/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit for the above allegation. LPA arrived at the facility at 10:00 a.m. and was greeted by the administrator Jozam Batulan. LPA explained to Administrator the purpose of the visit. Entrance interview conducted.

At 10:10 a.m. LPA and administrator Jozam conducted a physical plant tour to ensure the health and safety of the residents in care. No issues or concerns were observed.

Allegation: Facility staff did not provide records to resident's authorized representative.
It is alleged facility did not provide copies of Resident #1's (R1) facility records to R1's legal representative. To investigate the allegation LPA conducted an interview with the Reporting Party (RP) on 07/21/2023 and an interview with the facility administrator on 07/26/2023. Interview with administrator revealed person(s) listed on R1's Admission Agreement were designated representative(s) for R1. (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: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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-20230718160426

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: ANNIKA GRACE CARE HOME	FACILITY NUMBER: 197610178
	VISIT DATE: 10/09/2023

NARRATIVE

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On 07/26/2023 LPA reviewed and obtained copies of R1's records relevant to the investigation. LPA's review of R1's Admission Agreement, revealed R1 was admitted to the facility and the responsible person(s) listed on the document is different from representative mentioned in this complaint. Furthermore, LPA did not find a legally binding document on file that designates the representative mentioned in this complaint as conservator or POA. Based on record review and interviews, the allegation facility staff did not provide records to resident's authorized representative is Unsubstantiated at this time.

No deficiencies issued. Exit interview conducted. Report signed and delivered.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC9099 (FAS) - (06/04)

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