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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800506
Report Date: 05/31/2024
Date Signed: 05/31/2024 02:11:40 PM

Document Has Been Signed on 05/31/2024 02:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GAYNFAIR HOUSEFACILITY NUMBER:
405800506
ADMINISTRATOR/
DIRECTOR:		NEREIDA LEALFACILITY TYPE:
735
ADDRESS:545 GAYNFAIR TERRACETELEPHONE:
(805) 473-3542
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY: 6CENSUS: 6DATE:
05/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:05 AM
MET WITH:Nereida Leal, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon and Tri-Counties Regional Center Quality Assurance (QA) Magana conducted a case management visit to the facility above. LPA and QA met with Nereida Leal and explained the purpose of the visit.

LPA requested the following records from the facility: LIC. 500 Staff Roster with telephone numbers, Staff schedule for May, Staff 1, 2, 3's (S1)(S2)(S3) Disciplinary records/ write ups, 2024 Staff Training on Personal Rights, Crisis Prevention Institute (CPI), Abuse/Neglect Training for all staff, Copy of Mandated Reporter forms for all staff, Copy of Corporations Reporting Policy and Procedures, Resident 1 & 2 (R1) (R2) Behavioral Reports, ID and information form, most Appraisal Needs and Services Plan (ANS) or IPP, and LIC. 602A Physicians Report.

LPA and QA interviewed Administrator.

LPA reviewed incident reports for two residents at the facility alleging staff abuse of and self reported by the facility.

The facility sent LPA a copy of the current internal investigation report and the findings of the report have not been determined at this time.

The internal investigation revealed a staff admitting to telling R1 that R1 would have to take a cold shower if R1 did not listen which is not an allowed re-direct with R1's behavior plan.

LPA will need further time to investigate the alleged staff abuse of hitting R1 and R2.

Exit interview conducted, Deficiency cited, copy of report and appeal rights printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/31/2024 02:11 PM - It Cannot Be Edited


Created By: Rachael De Leon On 05/31/2024 at 01:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GAYNFAIR HOUSE
FACILITY NUMBER: 405800506

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2024
Section Cited
CCR
80072(a)(3)

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(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including... interference with the daily living... This requirement was not met as evidenced by:
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Administrator will have all staff working or filling in at the facility re-take Personal Rights, Rights of Persons with Disabilities, Mandated Reporting, and Abuse reporting training's, reviewing all residents IPP,ANS and Behavioral plans and provide proof of training, staff signatures and training material to CCL.
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Based on record review the Licensee did not comply with the above regulation, staff was not using proper language to re-direct a resident by telling R1 that R1 would have to take a cold shower which poses a potential Personal Rights 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.
SUPERVISOR'S NAME:Kelly Burley
LICENSING EVALUATOR NAME:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
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