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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800130
Report Date: 01/24/2024
Date Signed: 01/24/2024 03:50:54 PM

Substantiated


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
01/18/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20240118095524
FACILITY NAME:C.A.L.L.-RAMONA HOUSEFACILITY NUMBER:
405800130
ADMINISTRATOR:JAMI WESTFACILITY TYPE:
735
ADDRESS:3355 RAMONA ROADTELEPHONE:
(805) 466-2909
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:4CENSUS: 4DATE:
01/24/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tim Paulsen, Facility SupervisorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff spoke inappropriately to client.
Facility staff did not follow needs and services plan.
Facility staff did not dispense medications as prescribed.
Facility staff did not seek timely medical attention for client.
Facility staff did not assist client with medication refills.
Facility does not have an administrator.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Facility Supervisor Tim Paulsen and explained the purpose of the visit.
LPA De Leon requested the following documentation: Resident Roster, Staff Roster with telephone numbers, Incident reports for 01/11/2024 and 01/14/2024, Staff Schedules from 11/2023-01/2024, Staff Training records for 2023-2024, Appraisal Needs and Services Plans for all 4 residents, Copy of MAR for R1, Copy of Medical visit for R2, Picture of R3's PRN Medication, MAR, and PRN information.
On the allegation: Facility staff did not seek timely medical attention for client. Based on interview with staff, resident 2 (R2) was having loose stool for about 2 weeks and staff was unable to get an appointment for R2 after several calls. after about 2 weeks of the loose stools were not subsiding staff took R2 to Immediate Care at CHC in Templeton to be seen, tests were ran and 1 test is still pending and awaiting doctor orders. R2 had a previous doctor prescribed PRN medication for loose stool but none of the staff provided the PRN medication to R2 for relief of the symptoms. Based on the evidence this allegation is Substantiated at this time.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
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 5
Control Number 29-AS-20240118095524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L.-RAMONA HOUSE
FACILITY NUMBER: 405800130
VISIT DATE: 01/24/2024
NARRATIVE
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On the allegation: Facility staff did not assist client with medication refills. Based on interview with staff Resident 3 (R3) missed 11 days of the medication Guanfacine 2mg 3x's per day due to the pharmacy not being able to refill the medication without a doctor approval. An appointment was made for R3 to go to the doctor on March 5, 2024, due to appointment being made to far out and R3 being out of the medications phone calls were made between the pharmacy and the program to get the medication filled immediately. The medication was filled and R3 is getting the medication as prescribed. Based on the evidence this allegation is Substantiated at this time.

On the allegation: Facility does not have an administrator. Based on interview with staff the facility administrator left the position on 11/28/2023 and no valid administrator or LIC 308 Designation of facility responsibility was completed within the 30 days of the old Administrator leaving. The facility hired a new Facility Supervisor on 11/23/2023 to oversee the operation until a new administrator could be appointed. The facility supervisor is in the process of taking all the needed classes, training's and continuing education requirements to become the facility Administrator. Based on the evidence this allegation is Substantiated at this time.

Exit interview conducted, deficiencies cited and copy of report and appeal rights printed for staff.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20240118095524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: C.A.L.L.-RAMONA HOUSE
FACILITY NUMBER: 405800130
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2024
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 requirement was not met as evidenced by:
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The Licensee agreed to conduct training on 80075 with all staff working in the facility as well as the policies and procedures for medical attention for residents, provide proof of training with staff signatures, topics covered and an up to date LIC 500 with current staff working in the facility.
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Based on interviews the licensee did not comply with the regaultion above R2 was not taken to the doctor when having symptoms which poses a immediate Health and Safety risk to residents in care.
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Type A
01/26/2024
Section Cited
CCR
80075(b)(5)(B)
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(b)(5)... the licensee shall be permitted to assist the client with self-administration, providing all of the following requirements are met:(B)Once ordered by the physician the medication is given according to the physician's directions.
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Licensee agreed to review regulation 80075 and facility policy and procedures on medications and provide proof of training and an up to date LIC 500 for all staff working at the facility.
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Based on interview and record review the Licensee did not comply with the regulation above R3's medication Guanfacine was not given for 11 days due to the facility no getting the refills timely which poses an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20240118095524
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: C.A.L.L.-RAMONA HOUSE
FACILITY NUMBER: 405800130
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/31/2024
Section Cited
CCR
85061(b)(1)(2)(3)(A)
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(b) The licensee shall notify the licensing agency, in writing, within 30 days of a change of administrator. Such notification shall include the following: (1)...(2)...(3)...(A)...
This requirement was not met as evidenced by:
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Licensee will read/review and have an understanding of regulation 85061, will provide an LIC 308 giving designation to Facility Supervisor, appoint a qualified administrator to the facility and provide required paperwork to CCL.
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Based on interview and record review the Licensee did not comply with the regulation above, Administrator on record vacated the postilion on 11/28/2023 and no replacement Administrator has been appointed which poses a potential Safety risk to residents 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5