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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 401700013
Report Date: 06/08/2022
Date Signed: 06/08/2022 01:04:26 PM

Unsubstantiated


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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20220124142819
FACILITY NAME:ATASCADERO CHRISTIAN HOMEFACILITY NUMBER:
401700013
ADMINISTRATOR:CHRIS WOHLWENDFACILITY TYPE:
740
ADDRESS:8455 SANTA ROSA ROADTELEPHONE:
(805) 466-0281
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:64CENSUS: 11DATE:
06/08/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:CHRIS WOHLWEND/AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not notify resident's responsible party of resident's transfer to another facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 At 10:00am on 06/08/2022, Licensing Program Analyst (LPA) Mark Jeffries arrived at the facility to issue final findings to the complaint allegation above. LPA met with Administrator Chris Wohlwend.
As to the allegation of, “Facility did not notify resident's responsible party of resident's transfer to another facility.” Based on documentation and interviews, it was discovered that R1 had an Advanced Health Care Directive (AHED), signed, notarized and certified on August 28, 2019 indicating that F1 was designated and appointed agent in R1’s AHED document. The AHCD did have an alternate person listed, however, the AHCD stated within the contract that the alternat appointee would only be if, “F1 is not reasonably available, able, or willing, or becomes ineligible to act as agent to make healthcare decisions … or if (R1) revokes the appointment … then (R1) designated the following person to serve as agent.” This did not apply at the time of the medically necessary transfer of R1 to a higher level of care facility at the time of transfer on December 16, 2021. Therefore, the allegation of “Facility did not notify resident's responsible party of resident's transfer to another facility.” Is unsubstantiated, at this time.
Exit interview, Report signed, and copy provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
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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