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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603665
Report Date: 07/23/2024
Date Signed: 07/23/2024 04:26:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2024 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240715113138
FACILITY NAME:PRISTINE CARE 1FACILITY NUMBER:
198603665
ADMINISTRATOR:VANKINA, VENKATESWARAFACILITY TYPE:
735
ADDRESS:14639 DALMATIAN AVETELEPHONE:
(720) 272-7437
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:4CENSUS: 3DATE:
07/23/2024
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Venkateswara Vankina - Administrator TIME COMPLETED:
04:40 PM
ALLEGATION(S):
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Personnel records are not complete
Facility failed to report and update plan of operations
Facility does not have sufficient required training
Facility does not have client's physician's order
Facility staff failed to meet clients' needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent complaint visit to address the allegations listed above. LPA met with Venkateswara Vankina, Administrator for the facility, and explained the purpose of the visit.

The investigation consisted of the following: During the initial visit conducted on 7/22/2024, LPA interviewed Staff #1 (S1), Clients #2 - 4 (C2 - C4), and reviewed staff files #1 - 3 (S1 - S3). During today's visit, LPA interviewed Staff #2 - 3 (S2 - S3), reviewed the Medication Administration Records (MARs) for Client #1 (C1) - C4, and also reviewed the staff files for Staff #4 - 9 (S4 - S9). LPA was not able to interview C1 because they no longer live at the facility.

The investigation revealed the following: In regards to the allegation that "Personnel records are not complete," it is alleged that staff files are missing their Tuberculosis (TB) clearance, Physician's Stamp, Crisis Prevention Institute (CPI) certificates, and Direct Support Staff (DSP) certifications.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/15/2024 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240715113138

FACILITY NAME:PRISTINE CARE 1FACILITY NUMBER:
198603665
ADMINISTRATOR:VANKINA, VENKATESWARAFACILITY TYPE:
735
ADDRESS:14639 DALMATIAN AVETELEPHONE:
(720) 272-7437
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:4CENSUS: 3DATE:
07/23/2024
UNANNOUNCEDTIME BEGAN:
08:26 AM
MET WITH:Venkateswara Vankina - Administrator TIME COMPLETED:
04:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Administrator not present at the facility the necessary number of hours
Staff mismanaged client's medications
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Erik Zaragoza conducted a subsequent complaint visit to address the allegations listed above. LPA met with Venkateswara Vankina, Administrator for the facility, and explained the purpose of the visit.

The investigation consisted of the following: During the initial visit conducted on 7/22/2024, LPA interviewed Staff #1 (S1), Clients #2 - 4 (C2 - C4), and reviewed staff files #1 - 3 (S1 - S3). During today's visit, LPA interviewed Staff #2 - 3 (S2 - S3), reviewed the Medication Administration Records (MARs) for Client #1 (C1) - C4, and also reviewed the staff files for Staff #4 - 9 (S4 - S9). LPA was not able to interview C1 because they no longer reside at the facility.

The investigation revealed the following: In regards to the allegation that "Administrator not present at the facility the necessary number of hours, it is alleged that S4, who is the listed administrator of the facility, is hardly ever at the home.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 28-AS-20240715113138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PRISTINE CARE 1
FACILITY NUMBER: 198603665
VISIT DATE: 07/23/2024
NARRATIVE
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During interviews with the staff members, none corroborated the allegation that the administrator is not present during the necessary number of house, because the true administrator for the facility is Venkateswara Vankina. During interview with Venkat, he explained that he works at the facility most days during the week, up to around 60 hours per week. Venkat stated that it is true that S4 is not at the facility often, however he is acting as an advisor to him as an administrator, and that it is more accurate to say that rather than S4, Venkateswara himself is the administrator of the facility. Venkateswara stated that he will initiate the process to change the listed administrator on record to himself rather than S4. During interviews with the clients, none of them corroborated the allegation that the facility does not have an administrator on the facility premises often. One of the clients interviewed stated that it is true that S4 is not present at the facility often, however they stated that Venkat is often present in the home. Record review revealed that Vekateswara's administrator certificate was renewed on 1/20/2024 and expires on 1/19/2026.

In regards to the allegation that "Staff mismanaged client's medications," it is alleged that there were long stretches in the client's MARs in which they did not receive medication. During interviews with the clients, none of them corroborated that staff have mishandled their medications. One of the clients interviewed stated that they always received their required medications on time and have never had any issues with obtaining their medications. During interviews with the staff, none of them corroborated the allegation that they have mismanaged any of the client's medications. One of the staff interviewed stated that C1 had only been residing in the home as a respite resident, and therefore was only present in the facility a couple days at a time, and most of the time was residing at their parents home. Therefore the reasons for the long stretches during which C1 was not taking medications was due to C1 not being present within the home, however staff stated they did distribute C1's medications to them during the days in which they were staying in the home. There were no inconsistencies in the MARs for C2 - C4.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 28-AS-20240715113138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PRISTINE CARE 1
FACILITY NUMBER: 198603665
VISIT DATE: 07/23/2024
NARRATIVE
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During interviews with the staff members, none of them corroborated the allegation. One of the staff members interviewed stated that all health screenings for the staff members were signed by their physician, all caregivers have passed their DSP year 1 if recently hired and also their DSP 2 within the required time frames, and that all staff have a TB clearance as well. Staff stated that they understood that CPI certificates can be obtained within the first sixty (60) days of employment, which is the reason why one (1) out of nine (9) staff members do not currently have a CPI certificate. During record review, LPA confirmed that all staff have a signed physician's report with TB clearance as well as their DSP certifications. LPA also noted that one (1) staff member who was recently hired by the facility within the past month does not have a current CPI certificate, and during the review of the Plan of Operation, it did not indicate that staff will obtain their CPI certificate within the first 60 days of employment.

In regards to the allegation that the "Facility failed to report and update plan of operations," it is alleged that that the facility had installed video cameras within and outside of the facility, of which it was indicated only the outside camera was functioning. During interviews with the staff, it was revealed that cameras were installed at one point within the facility, however they have been taken down since then. During a tour of the facility, LPA observed disconnected electrical cables in the dining room cables and underneath the roof on the outside of the facility, which is where the video cameras were once installed but have since been removed. During record review of the plan of operation, and admissions agreements for the clients, there was no mention that there would be any use of video cameras on the premises of the facility. The administrator agreed that if the facility plans to re-install the cameras, they will update the facility plan of operation and admissions agreements for the clients and submit them to the LPA.

In regards to the allegation that the "Facility does not have sufficient required training," it was alleged that some of the facility staff had received First Aid/CPR training through online visual learning rather than receiving their training in-person in a hands on manner. During interviews with the staff, it was revealed that there are some staff members who receiving their First Aid/CPR training renewals through online rather than in-person. The administrator for the facility stated that he is still working on confirming who received their First Aid/CPR training online rather than in person, and will be scheduling these staff members to retake their training to ensure that it is done in-person.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 28-AS-20240715113138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: PRISTINE CARE 1
FACILITY NUMBER: 198603665
VISIT DATE: 07/23/2024
NARRATIVE
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In regards to the allegation that "Facility does not have client's physician's order," it is alleged that the facility did not have C1's physician's orders on file. During interviews with the staff, they confirmed that they never received the physician's orders for C1. One of the staff interviewed explained that C1 that they never obtained the physician's orders for C1 due to them being a respite resident of the facility, which meant they were only at the facility for a couple of days at a time, and for most of the time they resided at their parents home. The Administrator explained that C1's parents that were in possession of the former client's physician's orders, and would provide them to the facility staff for the period of time during which C1 would stay at the home, however they would return the physician's orders to the parents whenever C1 would return to see the parents home from the facility. LPA determined that copies of the physician's orders should have been made and maintained at the facility during C1's stay at the facility.

In regards to the allegation that "Facility staff failed to meet clients' needs," it is alleged that C1 experienced a seizure while residing at the home, and that after this occurred emergency services were never contacted, and there were concerns that the other clients needs were not being met. During interviews with the clients, one (1) out of three (3) clients corroborated the allegation that their needs were not being met. One client stated that they believe their emotional health needs were not being met, and stated that although their relationship with staff has been improving, they felt they have been treated in a rude manner in the past by staff. During interviews with the staff, none of them corroborated the allegation. One of the staff interviewed explained that C1 began displaying symptoms of having a seizure at 9:05 AM on 7/1/2024, and afterwards contacted C1's parents as well as C1's primary doctor to confirm that C1 was experiencing a seizure. Following this at around 11:30 AM, C1 began to returned to baseline and returned to their mothers house afterwards, however C1 was not taken to the local emergency room for an evaluation.

Based on LPA interviews conducted with the clients and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapters 1 and 6 are being cited on the attached LIC9099Ds.

Exit interview held and a copy of the report and appeal rights was provided to the administrator Venkateswara Vankina.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 28-AS-20240715113138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PRISTINE CARE 1
FACILITY NUMBER: 198603665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2024
Section Cited
CCR
85165(b)(2)
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(b) Staff (...) shall have a minimum of sixteen hours of emergency intervention training and be certified for having successfully completed the training. (2) Staff shall maintain valid certification.

This regulation is not met as evidenced by:
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Administrator is to ensure the all staff members have active CPI certificates in their file at all times. Administrator is to obtain the CPI identified for the identified staff and email it to LPA by the POC due date.
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Based on record review, one (1) out of nine (9) staff do not have a current CPI certificate in their records, which poses a potential health and safety risk to clients in care.
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Type B
08/06/2024
Section Cited
CCR
80022(j)
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(j) Any changes in the plan of operation which affect the services to clients shall be subject to licensing agency approval and shall be reported as specified in Section 80061.

This regulation is not met as evidenced by:
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**POC Cleared** LPA observed that all video cameras have been uninstalled from the facility, and will clear the POC. Administrator shall submit an updated plan of operations to LPA if the facility decides to resume the use of video cameras in the facility.
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Based on interview and observation, LPA determined that at one point video cameras were installed inside and outside the facility without being included in the facility's plan of operation or their admission agreements, which posed a potential health and sfaety risk.
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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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 28-AS-20240715113138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PRISTINE CARE 1
FACILITY NUMBER: 198603665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2024
Section Cited
CCR
80075(f)
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(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This regulation was not met as evidenced by:
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Administrator is to ensure that all staff receive their CPR training in person. Administrator is to identify all of the staff members who did not obtain their CPR renewal in person, conduct in-person retrainings with them, and email proof of their retrainings to LPA by the POC due date.
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Based on interview and record review, it was determined that certain staff in the facility obtained their CPR card renewals based on online training rather than hands on in-person training, which poses a potential health and safety risk to clients in care.
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Type B
08/13/2024
Section Cited
CCR
80075(b)(5)(A)
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(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription (...) staff shall be permitted to assist [if] (...) (A) There is a written direction from a physician, on a prescription blank.
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Administrator is to ensure that they have physician's orders for all clients in the facility at all times. Administrator is to email LPA the facility's plan for how they will ensure that the regulation is met moving forward by the POC due date.
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This regulation is not met as evidenced by:
Based on interview and record review, LPA determined that the facility did not make copies of C1's Physician's Orders while they were residing in the facility, which posed a potential health and safety risk to clients 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 28-AS-20240715113138
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: PRISTINE CARE 1
FACILITY NUMBER: 198603665
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2024
Section Cited
CCR
80075(a)
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(a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
This regulation is not met as evidenced by:
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Administrator is to ensure that each client receives necessary emergency medical services when necessary. Administrator is to email LPA the facility's plan on how they will ensure the regulation is met moving forward by the POC due date.
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Based on interview and record review, LPA determined that C1 did not receive emergency services from the facility staff for over 2 hours after experiencing a seizure, which posed a potential health and safety risk to clients 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8