405800577-8-25-2022-29-AS-KBUY-CHSMA2-20220830092536

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:13:29 PM

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
09/23/2020 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20200923102912

FACILITY NAME:	VILLAGE AT SYDNEY CREEK, THE		FACILITY NUMBER:	405800577
ADMINISTRATOR:	KIRK P KOTTHOR		FACILITY TYPE:	740
ADDRESS:	1234 LAUREL LANE		TELEPHONE:	(805) 543-2350
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	84	CENSUS: 45	DATE:	08/25/2022
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Kirk Klotthor, Executive Director/Administrator		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Facility staff did not treat resident with respect

INVESTIGATION FINDINGS:

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On 8/25/22 at 11:50 am, Licensing Program Analyst (LPA) Chavez conducted an unannounced complaint investigation visit to the facility listed above. LPA met with Kirk Klotthor, Executive Director/Administrator and explained the purpose of the visit.

On the allegation “Facility staff did not treat resident with respect,” the complainant was concerned that there was a Staff #7 (S7) who was "purposefully antagonize Resident #1 (R1) to make them agitated so the S7 member can call for a PRN to sedate the resident." To investigate the allegation, LPA interviewed staff and attempted to interview witnesses, and reviewed records.

Continued on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

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-20200923102912

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: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
	VISIT DATE: 08/25/2022

NARRATIVE

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On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3). S1 and S2 they had no knowledge of the incident. S3 says they witnessed Staff #7 (S7) “antagonize R1, go up to R1 and look R1 in the eyes, stare at R1, and use mannerisms to get a negative reaction.” S3 says they witnessed this “One or two times, mid-morning and at lunch time.” S3 says they reported this to the Wellness Coordinator shortly after the incident.

On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed Staff #4 (S4) and Staff #5 (S5). S4 and S5 say they did not witness any staff being disrespectful to residents.

On 8/19/22 at 10:04 am, LPA attempted to interview Witness #6 (W6) who may have had knowledge of the alleged incident. At the time this report was written, LPA did not hear back from W6.

On 8/22/22 at 11:55 am, LPA attempted to interview former Staff #7 (S7) who alleged to have disrespected R1. At the time this report was written, LPA did not receive a callback from S7.

On 8/22/22 at 1:03 pm, LPA spoke with Staff #5 (S5). LPA requested a copy of the incident report submitted by S3. S5 states that there are “No records of incidents with S7.” S5 explains that “If there were a complaint, it would have gone to the wellness coordinator which at the time was Staff #8 (S8) and now Staff #9 (S9).”

On 8/24/22 at 2:04 pm, LPA spoke with S9. S9 states they don’t “Have access to records,” that staff only verbalize incidents to S9. At 2:09 pm, LPA spoke with the Administrator. Administrator states that “We don’t have a document for staff to submit incidents, it’s only a verbal statement.” He states that S7 had no write-ups. At 3:45 pm, LPA reviewed the records of staff who had been counseled from January to September 2020. S7 had not been written-up.

Based on the evidence obtained, the allegation “Facility staff did not treat resident with respect,” is deemed Unsubstantiated at this time. There is insufficient evidence from interviews and documentation to determine whether S7 had been disrespectful to R1.

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

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene Chavez	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

LIC9099 (FAS) - (06/04)

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