405800361-12-15-2022-29-AS-KBUY-CMAPDA-20221220101313

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800361
Report Date: 12/15/2022
Date Signed: 12/15/2022 09:40:32 AM

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
08/04/2021 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20210804135150

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: 53	DATE:	12/15/2022
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Jodi Beltrama, Administrator		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Illegal eviction
Staff do not respond to resident's call light in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint investigation. LPA met with Administrator Jodi Beltrama and explained the purpose of the visit.

LPA De Leon conducted the initial 10-day complaint visit on 08/09/2021 at 2:30pm, interviewed staff and collected records. LPA De Leon conducted additional interviews on 08/11/2021 and on 12/06/2022 at 12:39pm. LPA De Leon reviewed records on 12/05/2022 and 12/06/2022.

On the allegation: Illegal eviction. LPA De Leon conducted interviews with staff and witnesses which revealed a care conference regarding Resident 1 (R1) was held due to change in condition and frequent falls. Continued 9099-C

Unsubstantiated

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: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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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Control Number 29-AS-20210804135150

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: 12/15/2022

NARRATIVE

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Facility staff initiated the care conference with responsible parties (RP’s) of R1 due to concerns the facility had experienced with R1. The care conference was held and the RP’s agreed with a change in condition and relocation of R1. RP found placement with the help of the facility and hired movers to move R1 on 08/06/2021 and provided facility with this move out date. The facility did not evict or issue an eviction to the resident or the RP’s of the resident. R1 diagnosis (dx) did change and was updated on an LIC 602A Physicians report and given to the facility on or after 08/04/2021. R1’s new dx would have warranted an eviction by the facility as the facility would not have been able to meet R1’s needs, the RP had already given notice and made arrangements to move R1 out of the facility on 08/06/2021 so the Facility did not have to issue an eviction letter. Based on the evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Staff do not respond to resident's call light in a timely manner. LPA requested records of R1’s call pendant and reviewed those records, The records indicated that between 06/11/2021 and 7/31/2021 R1’s pendant alarmed 27 times. Only 5 out of 27 pendant alarms were over 10 minutes. On those 4 occasions the call was acknowledged by staff within minutes and then cleared by staff within 10:05 minutes/seconds, 32:12, 18:28 and 18:38 minutes/seconds. One alarm call was over 4 hours due to the family taking the residents out of the facility and not leaving the pendant. The staff acknowledged the calls timely and cleared most of them within the 10 minutes. Based on the evidence in this case the allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to the administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC9099 (FAS) - (06/04)

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