<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530014
Report Date: 06/08/2023
Date Signed: 06/08/2023 11:30:56 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2023 and conducted by Evaluator Anna Bueno
COMPLAINT CONTROL NUMBER: 56-AS-20230602085022
FACILITY NAME:LONG MEADOW HOMEFACILITY NUMBER:
365530014
ADMINISTRATOR:CARR JR., MICHAELFACILITY TYPE:
735
ADDRESS:13170 LONG MEADOW ST.TELEPHONE:
(818) 309-7821
CITY:HESPERIASTATE: CAZIP CODE:
92344
CAPACITY:4CENSUS: 2DATE:
06/08/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Loraine KenevanTIME COMPLETED:
11:35 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff called the resident inappropriate names.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the complaint investigation and deliver findings on the above allegation. LPA met with administrator Loraine Kenevan who was informed of the purpose of today’s visit. The investigation consisted of staff and witness interviews and records review.

The allegation is Staff (S1) called the resident (R1) inappropriate names. Interviews with witness confirm that they observed S1 refusing to provide R1 activities of daily living (ADLs). Staff interviews stated that another resident observed S1 talk about R1 and used inappropriate names. Records revealed that S1 was observed and heard S1 call R1 inappropriate names. This complaint is therefore SUBSTANTIATED meaning that the allegation is valid because the preponderance of the evidence standard has been met. This poses a potential risk to the health and safety risk to residents in care.

Refer to LIC809-D for deficiency cited. An exit interview was conducted where this report, LIC809-D, and appeal rights were discussed with and provided to Administrator Kenevan.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
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 2
Control Number 56-AS-20230602085022
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: LONG MEADOW HOME
FACILITY NUMBER: 365530014
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/08/2023
Section Cited
CCR
80072(a)(3)
1
2
3
4
5
6
7
To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
1
2
3
4
5
6
7
Licensee shall remove S1 from the facility.

As of today's visit, S1 is no longer associated to this facility. This POC is therefore satisfied.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

Interviews with staff confirmed and records review revealed that that S1 used inappropriate names on R1
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2