198320378-5-16-2024-11-AS-SCIS-D5HQCH-20240522120311

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320378
Report Date: 11/15/2023
Date Signed: 05/16/2024 11:13:08 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2023 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20231025163724

FACILITY NAME:	HOLIDAY VILLA		FACILITY NUMBER:	198320378
ADMINISTRATOR:	ZENOU, ADAM		FACILITY TYPE:	740
ADDRESS:	1447 17TH STREET		TELEPHONE:	(310) 829-5904
CITY:	SANTA MONICA	STATE: CA	ZIP CODE:	90404
CAPACITY:	174	CENSUS: 38	DATE:	11/15/2023
		UNANNOUNCED	TIME BEGAN:	10:26 AM
MET WITH:	Ruby Cruz, Business Office Manager		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Licensee does not ensure the facility is free from pest.
Licensee does not provide adequate food services for residents.

INVESTIGATION FINDINGS:

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**This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 11/15/23.

On 11/15/23 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived at 10:26am and spoke to Wellness Director Amber Lollar and explained the purpose of the visit is to deliver findings for the allegations mentioned above and was granted access to the facility.

The investigation consisted of the following:

On 11/1/23 LPA reviewed resident files and toured the facility. LPA reviewed and requested copies of the following records: Client Roster, Staff roster, LIC 500, weekly menus, fumigation service records, and staff training.

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

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 11-AS-20231025163724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 11/15/2023

NARRATIVE

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The investigation revealed the following:

Allegation: Licensee does not ensure the facility is free from pests

On 11/1/23 LPA conducted interviews with both staff and residents. LPA Shirley reviewed the service reports from Orkin for the months of September and October of 2023. During review, LPA observed that the facility is serviced every 2 weeks. There is a comment section on the report where the technician list the services and treatments done for the days serviced. LPA did observe ongoing treatment for termites and cockroaches, but there is no activity found on service dates. LPA interviewed staff, staff 1 – staff 4 (S-1 – S-4). LPA asked if they had observed termites or cockroaches in the facility. Of those interviewed 4 out of 4 stated no. LPA interviewed residents 1 – resident 6 (R-1 – R-6). LPA asked residents, if they had observed termites or cockroaches in the facility. Of those interviewed, 4 out of 6 answered, No.

Based on information gathered, the department did not find sufficient evidence to support allegations "Licensee does not ensure the facility is free from pests. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Licensee does not provide adequate food services for residents

On 11/1/23 LPA conducted interviews with both staff and residents. LPA Shirley reviewed kitchen staff files and observed that both food handlers are accredited with certificates of completion for California Food Handlers.

Cont'd on 9099-C

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231025163724

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: HOLIDAY VILLA	FACILITY NUMBER: 198320378
	VISIT DATE: 11/15/2023

NARRATIVE

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LPA reviewed weekly menus and found that there are nutritionally balanced meals listed and a healthy balance of both cold and hot meals. There are also available options listed on the bottom of weekly menus offering both hot and cold deli sandwiches. LPA observed hair nets on kitchen staff during interviews as it is a requirement to enter the kitchen. LPA interviewed staff and ask them if they believed that the meals are well balanced and nutritious. LPA interviewed staff S-1 through S-4 (S-1 – S-4). Of those interviewed 4 out of 4 answered yes. LPA interviewed residents R-1 through R-6 (R-1 – R6). LPA ask, do you think meals are nutritious? Of those interviewed, 3 out of 6 answered yes.

Based on information gathered, the department did not find sufficient evidence to support allegations "Licensee does not provide adequate food services for residents. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted and a copy of the LIC 9099 was provided to Ruby Cruz, Business Office Manager.

SUPERVISOR'S NAME: Stephanie Cifuentes	TELEPHONE: (661) 644-7743
LICENSING EVALUATOR NAME: Felisa Shirley	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

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