405800269-9-27-2024-29-AS-KBUY-D9LVPB-20240930163629

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800269
Report Date: 09/27/2024
Date Signed: 09/27/2024 11:35:18 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
10/04/2023 and conducted by Evaluator Erika Miller

COMPLAINT CONTROL NUMBER: 29-AS-20231004123019

FACILITY NAME:	M & L SOUTH BAY MAXI CARE		FACILITY NUMBER:	405800269
ADMINISTRATOR:	LITA C. LAZO		FACILITY TYPE:	740
ADDRESS:	1820 MOUNTAIN VIEW DRIVE		TELEPHONE:	(805) 528-7862
CITY:	LOS OSOS	STATE: CA	ZIP CODE:	93402
CAPACITY:	6	CENSUS: 1	DATE:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Lita Lazo, Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff handled resident in a rough manner
Staff hit resident
Staff are not able to effectively communicate with residents
Residents cannot have visitors without an appointment

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Rachael De Leon (De Leon) conducted an unannounced initial complaint visit to the facility above on 10/6/23. De Leon toured the inside and outside of the facility with Administrator. On September 27, 2024, LPA Miller met with Lita C. Lazo, Administrator, and issued final findings on the allegations above. LPA interviewed staff, reviewed relevant documentation and took a cursory tour of facility.

Allegation: Staff handled resident in a rough manner and hit residents
Reporting party (RP) alleges that there are only two residents who are verbal and complain about the treatment they receive at this facility. RP alleges that R1 stated that they have been hit in the face and dragged across the floor. RP stated that Resident 2 (R2), stated that she is frightened of staff.

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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 3

Control Number 29-AS-20231004123019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: M & L SOUTH BAY MAXI CARE	FACILITY NUMBER: 405800269
	VISIT DATE: 09/27/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Administrator advised that R1 passed away on 3/29/24 and provided copy of LIC 624 that was sent to CCL. Administrator advised that R2 vacated the facility in August of 2024 to move out of the local area. Administrator refutes the allegation in its entirety as they have never observed staff hit or handle residents in a rough manner. Administrator further stated that R1 wanted to leave the facility and live at her own residence, as evidenced in the hospice report dated 10/25/22.

Staff 1 (S1) has been working at facility since June of 2017 and never observed staff handle residents in a rough manner or hit residents. S1 claims they would have reported any abuse to administrator. S1 recalls two residents living at facility at the time of the allegation. Staff 1 recalls that R1 was aggressive and attempted to hit S1 in the face. S1 stated that they did not lay hands on R1, but blocked R1's hand. S1 recalls R1 making false statements about paying for other resident’s expenses. R1 was best friends with R2 , but they also argued. LPA reviewed R1’s medical assessment that reflects R1 had mild cognitive impairment.
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: Staff are not able to effectively communicate with residents

RP alleges that there is a language barrier between staff and residents. LPA observed that Administrator and S1 were able to communicate effectively in English.

Administrator and S1 stated they did not have trouble communicating with residents and that both residents were verbal and the time of the allegations. S1 stated that there was a staff member that left in January 2024, who had an Australian accent, but did not have an issue communicating with 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.

Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20231004123019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: M & L SOUTH BAY MAXI CARE	FACILITY NUMBER: 405800269
	VISIT DATE: 09/27/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Residents cannot have visitors without an appointment

RP stated they visited a resident every Wednesday and made appointments to visit R1 the exact time every week, since before the pandemic. Administrator and S1 stated that residents have never been required to schedule an appointment to have visitors. They have no knowledge of the arrangements the visitors made with R1. S1 further stated that in the past visitors often dropped by unannounced. The only resident on-site is currently sleeping and is unavailable to answer questions. There is no evidence to support that visitors are required to make appointments.

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 conducted, and a copy of this report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3