405800361-7-7-2021-29-AS-KBUY-C5BNHM-20210727102855

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800361
Report Date: 07/07/2021
Date Signed: 07/07/2021 03:51:25 PM

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
06/29/2021 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20210629114805

FACILITY NAME:	WYNDHAM RESIDENCE		FACILITY NUMBER:	405800361
ADMINISTRATOR:	JODI BELTRAMA		FACILITY TYPE:	741
ADDRESS:	222 S. ELM STREET		TELEPHONE:	(805) 474-7260
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	72	CENSUS: 52	DATE:	07/07/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jodi Beltrama, Administrator		TIME COMPLETED:	03:39 PM

ALLEGATION(S):

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Staff did not prevent a resident from wandering while in care
Staff did not properly report an incident regarding a resident to CCL

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above at 1:00pm on 07/07/2021. LPA met with Jodi Beltrama Administrator and explained the purpose of the visit.

LPA conducted interviews with staff and witnesses. LPA requested the following documentation: LIC 602 Physicians report for Resident 1 (R1), Pre-Appraisal for R1, Care Conference dates with family of R1, Incident report for the date of the incident, staff notes on room 120, and R1's profile emergency contacts numbers. All records requested were provided to LPA at the visit.

LPA reviewed records given.
Continued 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

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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Control Number 29-AS-20210629114805

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: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
	VISIT DATE: 07/07/2021

NARRATIVE

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On the allegation: Staff did not prevent a resident from wandering while in care. LPA interviewed and collected documentation which revealed staff failed to keep Resident (R1) from leaving the facility unassisted. LIC 602 physicians report was marked R1 was unable to leave the facility unassisted. According to Witness 1's (W1's) interview R1 had a family visit with her family and dog, the family left the visit shortly before dinner time on 06/25/2021. R1 did not sign out and wandered outside the facility undetected for around 30 minutes before staff realized she was not at dinner and began to search facility for R1. Facility staff notified Arroyo Grande Police Department and family. Staff started to search outside of the community and staff was able to locate R1 in the surrounding neighborhood. Staff was able to redirect R1 back to the community. Facility and family set up a care conference for the next day and R1 was taken home by family and eventually relocated to another facility that could met R1's changing needs. Therefore, the allegation is deemed Substantiated at this time.

On the allegation: Staff did not properly report an incident regarding a resident to CCL. Based on documentation and interviews the facility staff failed to report the incident to Community Care Licensing (CCL) on R1's wondering without supervision on 05/25/2021. Therefore, the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210629114805

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: WYNDHAM RESIDENCE	FACILITY NUMBER: 405800361
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/09/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	Basic Services (f)Basic services shall at a minimum include:(1)Care and supervision as defined ... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to set a system in place that identifies residents whom can not leave the facility unassisted and provide training to staff on those residents. Provide proof to CCL.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above, as R1 wandered from the facility without supervision which poses an immediate safety risk to resident in care.	8 9 10 11 12 13 14
Type B 07/07/2021 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements...(D) Any incident which threatens the welfare, safety or health of any resident ... or unexplained absence of any resident. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator did an incident report immediately for R1's elopement on 05/25/2021 and provided copy to LPA on visit. Administrator will submit all incident reports in the future to CCL.
	8 9 10 11 12 13 14	Based on record review, the Licensee did not comply with section cited above, Staff failed to report R1's incident to CCL which poses a potential safety risk to residents in care.	8 9 10 11 12 13 14

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021

LIC9099 (FAS) - (06/04)

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