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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800467
Report Date: 11/14/2024
Date Signed: 11/14/2024 05:14:32 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
11/07/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20241107133319
FACILITY NAME:GARDEN CREEKFACILITY NUMBER:
405800467
ADMINISTRATOR:LIZA HIXFACILITY TYPE:
740
ADDRESS:73 BROAD STREETTELEPHONE:
(805) 543-2311
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:72CENSUS: 46DATE:
11/14/2024
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Liza Hix, AdministratorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
1
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7
8
9
Staff did not seek medical attention in a timely manner for resident after a fall
Facility failed to report incident to Residents responsible party and Licensing
Facility failed to report resident death to Licensing
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Liza Hix, Administrator and explained the purpose of the visit.

LPA requested the following records: Resident Roster, Staff Roster, All incident reports on R1, Death report for R1, Procedure or policy for Reports, falls, discharge and extra care after discharge of residents at the facility, admission agreement for R1, refund of rent paid and refunded for R1, disciplinary report for staff, hospital discharge paperwork, and notes or charting for R1.
The facility was able to provide resident roster, staff roster, staff schedules for December 2023, R1's admission agreement, Refund of rent paid and refund issued, staff email to supervisor/managers reporting R1 going to Hospital. Facility was not able to provide any other records requested.

LPA De Leon conducted interviews with staff at 10:15am, 10:45am, 11:04am, 12:40pm, 12:50pm, 1:28pm, 2:06pm, 2:14pm, and 2:45pm,
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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 6
Control Number 29-AS-20241107133319
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: GARDEN CREEK
FACILITY NUMBER: 405800467
VISIT DATE: 11/14/2024
NARRATIVE
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On the allegation: Staff did not seek medical attention in a timely manner for resident after a fall. LPA conducted interviews with staff and witness that revealed Resident 1 (R1) did have a fall in the early morning, R1 was not wearing R1's pendant to call for help, R1 was on the floor calling for help for an unknown amount of time, and the facility did not call 911 or seek medical attention for R1. R1 had another fall that afternoon and 911 was called to transport R1 to the ER. Based on the evidence this allegation is Substantiated at this time.

On the allegation: Facility failed to report incident to Residents responsible party and Licensing. LPA conducted interviews with staff which revealed no 911 or medical visit was made for R1 after the 1st fall, R1's 2nd fall was reported immediately to R1's family. Incident report for either of R1's falls on12/30/2024 were not reported to Community Care Licensing (CCL). Witness 1(W1) interviewed revealed a call was made to W1 in the late morning 12/30/2024 regarding a fall for R1, R1 was fine, got cleaned up and taken down to breakfast. W1 stated later that afternoon W1 was immediately called about R1 having another fall and was being transported to the hospital. Based on the evidence and lack of facility records provided this allegation is Substantiated at this time.

On the allegation: Facility failed to report resident death to Licensing. LPA conducted interviews with staff and requested records of death report for R1. The facility was unable to provide a copy of the death report. W1 stated the facility staff was told about R1's death in the hospital within the days proceeding the death of R1, W1 cleaned out R1's room and gave away some of R1's belongings so certain staff knew of R1's death at that time. W1 stated R1's death was reported to management within the week of R1's passing. Based on the lack of records provided and CCL not having a death report on file this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights printed for administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20241107133319
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: GARDEN CREEK
FACILITY NUMBER: 405800467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
11/21/2024
Section Cited
CCR
87465(a)(2)
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2
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7
(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need... This requirement was not met as evidenced by:
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5
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7
Administrator agreed to train all care staff and med-techs on facilities policies for falls and calling 911, regulation 87465 and provide proof of training with staff signatures and an up to date LIC 500 for staff to CCL 11/21/2024.
8
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11
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14
Based on records review and interviews the Licensee did not comply with the regulation above, Staff did not seek medical attnetion for R1's fall which posses a potential Health, saefty and personal rights risk to residents in care.
8
9
10
11
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14
Type B
11/21/2024
Section Cited
CCR
87211(a)(1)(B)
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7
(a) Each licensee shall furnish to the licensing agency such reports...:(1)...(B)Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirment was not met as evidenced by:
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Administrator agreed to train all staff in reporting procedures/policy and regulation 87211 and provide proof of training with staff signatures and an up to date LIC 500 for staff to CCL 11/21/2024.
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Based on record review the Licensee did not comply with the regulation above, the facility did not report R1's falls on an incident report to CCL and did not report the first fall timely to R1's family which poses a potential health, safety and personal rights risk to residents in care.
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9
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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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20241107133319
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: GARDEN CREEK
FACILITY NUMBER: 405800467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/21/2024
Section Cited
CCR
87211(a)(1)(A)
1
2
3
4
5
6
7
(a) Each licensee shall furnish to the licensing agency such reports...:(1)...(A)Death of any resident from any cause regardless of where the death occurred,...This requirement was not met as evidneced by:
1
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3
4
5
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Administrtor agreed to train all staff in reporting procedures/policy and regulation 87211, reporting time/date for deaths and provide proof of trianing with staff signatures and an up to date LIC 500 for staff to CCL 11/21/2024.
8
9
10
11
12
13
14
Based on record review the Licensee did not comply with the regulation above, CCL did not receive a death report for R1 which poses a potential Health, safety and personal rights risk to reisdents in care.
8
9
10
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12
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14
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1
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7
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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: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
11/07/2024 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20241107133319

FACILITY NAME:GARDEN CREEKFACILITY NUMBER:
405800467
ADMINISTRATOR:LIZA HIXFACILITY TYPE:
740
ADDRESS:73 BROAD STREETTELEPHONE:
(805) 543-2311
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:72CENSUS: 46DATE:
11/14/2024
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Liza Hix, AdministratorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility denied care and supervision services after resident was discharged from the hospital
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Liza Hix, Administrator and explained the purpose of the visit.

LPA requested the following records: Resident Roster, Staff Roster, All incident reports on R1, Death report for R1, Procedure or policy for Reports, falls, discharge and extra care after discharge of residents at the facility, admission agreement for R1, refund of rent paid and refunded for R1, disciplinary report for staff, hospital discharge paperwork, and notes or charting for R1.
The facility was able to provide resident roster, staff roster, staff schedules for December 2023, R1's admission agreement, Refund of rent paid and refund issued, staff email to supervisor/managers reporting R1 going to Hospital. Facility was not able to provide any other records requested.

LPA De Leon conducted interviews with staff at 10:15am, 10:45am, 11:04am, 12:40pm, 12:50pm, 1:28pm, 2:06pm, 2:14pm, and 2:45pm,
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20241107133319
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: GARDEN CREEK
FACILITY NUMBER: 405800467
VISIT DATE: 11/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
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20
21
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25
26
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31
32
On the allegation: Facility denied care and supervision services after resident was discharged from the hospital. LPA interviewed staff which revealed no staff denied care or supervision services after a residents discharge, Staff stated they would provide the services immediately and let business staff know to up date care services on resident 1 (R1). Staff stated they understand the procedure to provide care immediately and business office sends a letter to resident and responsible parties of care fee increase. Witness 1 stated after discharge a staff told W1 they could not provide additional care services to R1 until the next business working day W1 would have to sign up for additional care services at that time. LPA reviewed R1's Admission Agreement and in Appendix A there is a clause that states Additional "Round the Clock" care the facility would provide the service for a fee of $25.00, the fee would be billed to the family on a weekly basis and will be expected to be paid within three days of receipt. Based on the lack of evidence this allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6