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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610299
Report Date: 03/28/2023
Date Signed: 03/28/2023 02:51:57 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
03/20/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20230320165422
FACILITY NAME:ALAMINOS HOMEFACILITY NUMBER:
197610299
ADMINISTRATOR:RAGASA, RUSKIEFACILITY TYPE:
740
ADDRESS:21514 ALAMINOS DRIVETELEPHONE:
(661) 993-4362
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY:6CENSUS: 4DATE:
03/28/2023
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Ruskie RagasaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff are not following proper COVID-19 mask guidance.
Facility not properly securing medications.
Facility cleaning supplies are accessible to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA met with the administrator, Ruskie Ragasa, and explained the reason for the visit.

--- Facility staff are not following proper COVID-19 mask guidance.

It was alleged that staff are not wearing masks while in the facility. To investigate this allegation, on 03/28/2023, LPA made observations during a physical plant tour at 9:30 AM and interviewed two (02) staff from 10:30 AM – 11:15 AM. Upon entry, LPA observed that all staff were not wearing masks. During the interviews, staff admitted to not following infection control protocols during a visit by other parties. Based on observations and interviews, the allegations are SUBSTANTIATED at this time.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):
(CONT. on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
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 4
Control Number 31-AS-20230320165422
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: ALAMINOS HOME
FACILITY NUMBER: 197610299
VISIT DATE: 03/28/2023
NARRATIVE
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--- Facility not properly securing medications.

It was alleged that staff are leaving medications unlocked and accessible to residents. To investigate this allegation, on 03/28/2023, LPA made observations during a physical plant tour at 9:30 AM and interviewed two (02) staff from 10:30 AM – 11:15 AM. During the physical plant tour, LPA observed that facility did not have medications in the refrigerator, however, staff left centrally stored medication unit unlocked with key hanging on the door. During interviews, staff admitted to leaving the medication unit unlocked during a visit by other parties.

Based on observations and interviews, the allegations are SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

--- Facility cleaning supplies are accessible to residents in care.

It was alleged that staff are storing toxins in an unlocked storage closet. To investigate this allegation, on 03/28/2023, LPA made observations during a physical plant tour at 9:30 AM and interviewed two (02) staff from 10:30 AM – 11:15 AM. During the physical plant tour, LPA observed that facility had cleaning supplies and other toxins in an unlocked storage closet. During interviews, staff stated that they were cleaning earlier today and planned to lock it. Staff also admitted that the storage closet containing toxic cleaning supplies was unlocked during a visit by other parties.

Based on observations and interviews, the allegations are SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No health and safety hazards noted during the visit.

Exit interview was conducted and a copy of report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20230320165422
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: ALAMINOS HOME
FACILITY NUMBER: 197610299
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2023
Section Cited
CCR
87705(f)(2)
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87705 (f) Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87705 Care of Persons with Dementia; The written letter must be sent to the LPA by the POC due date.
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This requirement is not met as evidenced by: Based on observation and interviews, the licensee failed to ensure that items were inaccessible to residents with dementia, which poses an immediate health and safety risk to residents in care.
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Type B
03/30/2023
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87465 Incidental Medical and Dental Care; The written letter must be sent to the LPA by the POC due date.
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This requirement is not met as evidenced by: Based on LPAs observation and interviews, the licensee did not ensure that medication was kept locked and inaccessible to residents in care which poses a potential 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.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20230320165422
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: ALAMINOS HOME
FACILITY NUMBER: 197610299
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2023
Section Cited
CCR
87470(c)(1)(F)
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87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by;
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87470 Infection Control Requirements; The written letter must be sent to the LPA by the POC due date.
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Based on observations and interviews, the licensee did not ensure that staff are wearing mask at all times while at the facility and that all visitors are screened upon entry which poses an immediate health, safety and personal rights risk to residents 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.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4