197610361-9-27-2024-31-AS-TAGD-D9UPSE-20241008113412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610361
Report Date: 09/27/2024
Date Signed: 09/27/2024 02:25:48 PM

Unsubstantiated

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
08/26/2024 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20240826140000

FACILITY NAME:	LIBERTY RESIDENTIAL FACILITY		FACILITY NUMBER:	197610361
ADMINISTRATOR:	TILLMAN, WILDA W		FACILITY TYPE:	735
ADDRESS:	3330 RACQUET LANE		TELEPHONE:	(661) 916-9090
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	4	CENSUS: 4	DATE:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Jeanette Gonzalez		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Staff did not accord privacy to resident while in care.
Staff intereferred with resident's ability to participate in medical appointment(s).
Staff did not allow resident to communicate with their responsible party while in care.
Staff falsified documentation regarding resident in care.
Staff do not ensure that resident's hygiene needs are met while in care.
Staff do not ensure that resident's clothing needs are met while in care.

INVESTIGATION FINDINGS:

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On 9/27/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth met with the Administrator, Jeanette Gonzalez. LPA explained the purpose of this visit was to deliver the findings.

The investigation consisted of the following: On 8/28/2024, LPA conducted an initial visit and reviewed the residents' files at 2:40 pm until 3:00 pm. LPA interviewed three (C1 – C3) out of four clients. C4 was not available for an interview. LPA interviewed three out of the seven caregivers (S1-S3) and the Administrator at 3:00 pm until 3:30 pm. LPA requested copies of a client's records and the staff roster and phone numbers. LPA received the documentation during the visit.

LPA Spaeth interviewed the Licensee, Wilda Tillman on 9/23/2024 by phone at 10:00 am

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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-20240826140000

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: LIBERTY RESIDENTIAL FACILITY	FACILITY NUMBER: 197610361
	VISIT DATE: 09/27/2024

NARRATIVE

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Regarding the allegation: Staff did not accord privacy to resident while in care. It’s alleged the Licensee texts a client and tells them what to say to their doctor so that the client does not have to take medication. C1-C3 confirmed this has not occurred. S1-S3, the Administrator and the Licensee unanimously stated the Licensee would never interfere with a client’s conversation with their doctor.

Regarding the allegation: Staff interfered with resident's ability to participate in medical appointment(s). It’s alleged that the Licensee and facility staff interfere with a client’s medical treatment by telling the client there is nothing wrong with them and they do not need treatment. C1-C3 stated the Licensee, the Administrator, and staff have never made this statement. C4 was not available. S1-S3, the Administrator and the Licensee denied this has occurred.

Regarding the allegation: Staff did not allow resident to communicate with their responsible party while in care. It’s alleged that a client has not been allowed to speak to family members or to their Guardian. C1-C3 confirmed they speak to their family members and their Guardian. C1-C3 stated the Licensee, Administrator and staff have always allowed them to speak to anyone they choose. C4 was not available. S1-S3, the Licensee and the Administrator denied this has occurred.

Regarding the allegation: Staff falsified documentation regarding resident in care. – It’s being alleged that the Licensee and staff are providing false reports regarding a client’s behavior. LPA Spaeth reviewed the facility incident reports on 8/28/2024 and did not observe any indication of the report being falsified. The facility staff denied this has occurred. LPA spoke to a client regarding an incident; however, the client refused to give details to LPA Spaeth.

Regarding the allegation: Staff do not ensure that resident's hygiene needs are met while in care. It’s being alleged that a client’s hair is dirty, and the client has an odor. During LPA’s visit on 8/28/2024, C1-C3 unanimously stated they take a shower every morning. C4 was not available. S1-S3, the Administrator and the Licensee denied this has occurred.

Continued on 9099-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 31-AS-20240826140000

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: LIBERTY RESIDENTIAL FACILITY	FACILITY NUMBER: 197610361
	VISIT DATE: 09/27/2024

NARRATIVE

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Regarding the allegation: Staff do not ensure that resident's clothing needs are met while in care. It’s being alleged that a client wears the same clothing each day, the clothing is wrinkled and dirty. During LPA’s visit on 8/28/2024. C1-C3 confirmed they were wearing clean clothing; their clothing is not wrinkled and staff wash their clothing each week. LPA observed the clients were wearing clean clothing and there was no odor. S1-S3, the Administrator and the Licensee denied this has occurred.

Based on interviews and record review, the allegations are unsubstantiated.

Exit interview conducted and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

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