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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 09/14/2022
Date Signed: 09/14/2022 02:47:12 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
09/07/2021 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20210907122144
FACILITY NAME:VILLAGE AT SYDNEY CREEK, THEFACILITY NUMBER:
405800577
ADMINISTRATOR:KIRK P KLOTTHORFACILITY TYPE:
740
ADDRESS:1234 LAUREL LANETELEPHONE:
(805) 543-2350
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:84CENSUS: 47DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Kirk Klotthor, Executive Director/AdministratorTIME COMPLETED:
03:08 PM
ALLEGATION(S):
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Staff not meeting residents care needs.
INVESTIGATION FINDINGS:
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On 9/14/22 at 2:05 pm, Licensing Program Analyst (LPA) Chavez visited the facility to deliver final findings on a complaint investigation for the allegation listed above. LPA met with Kirk Klotthor, the facility administrator and explained the purpose of today’s visit.

On the allegation “Staff not meeting residents care needs,” the complainant was concerned that the facility had been short-staffed for the past few months and that “multiple residents needs are not being met.” To investigate, LPA interviewed staff and witnesses.

On 9/13/21 between 11:40 am and 1:54 pm, LPA interviewed Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Staff #4 (S4), Staff #5 (S5), Staff #6 (S6), and Staff #7 (S7). S1 says the facility has a high employee turnover and that currently, there are “3-4 newbies and 5-6 veterans.” S2 says, “we could have more concierge.” S3 states that the “facility is short-staffed” and explains that there are “18 residents and 2 caregivers and 1 concierge.”
Continued on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
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-20210907122144
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: 09/14/2022
NARRATIVE
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S3 says that residents have higher needs and there are “four heavy wetters who need changing every hour, others who need changing every two hours, and two residents who need a two-person assist.” S4 reports that there are two caregivers and one concierge per neighborhood and that “one to two times per month, we need more concierge in events.” S4 further explains that “At times, it is hectic, and we need more people.” S5 says there are “16-18 residents, 3 PCAs, and 1 concierge.” S5 explains that “3-4 staff work double shifts almost every day.” S6 says they work double shifts 2-3 times each week and that “lately it’s been worse.” S6 describes the situation, saying “new people quit quickly.” S7 explains that there are “a lot of people working double shifts since January 2021, at least 2-3 staff working double shifts daily.”

On 9/17/21 at 3:07 pm, LPA interviewed Witness #1 (W1). W1 says that they had to “train the staff on mom’s needs, i.e. changing her (diaper) regularly, feeding her properly and feeding her regularly, turning her, showering her.” W1 stated that they “were not taking care of her due to a shortage in staff, new staff not being trained fully, and too few caregivers to get the job done.”

On 7/21/22 between 2:15 pm and 2:59 pm, LPA interviewed Staff #8 (S8) and Staff # (S9). S8 says regarding incontinent needs that “It’s happened (residents not getting changed) about three times in the past 10 years.” S9 says they observed “Two staff who did not attend to residents’ toileting needs for more 30 minutes.” S9 further explains that “Staff are tired from working double shifts, and sometimes they don’t tend to residents’ needs.”

On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed Staff #10 (S10) and Staff #11 (S11). S10 reports that it is discussed with staff in crossover meetings. S10 says they do not know of any staff who had problems with changing residents’ diapers. S11 says “It happens sometimes. Staff may be helping other residents,” and S11 says they do not recall any staff in particular who did this.



On 8/11/22 at 1:22 pm, LPA spoke with Witness #2 (W2). W2 says that their mother is “Typically is taken care of, however, her teeth bothered her, and staff don’t really assist with brushing her teeth.” W2 explains “Her hair looks terrible. Staff does a great job considering I don’t think they have enough people.”

Based on the evidence obtained, the allegation “Staff not meeting residents care needs” is deemed Substantiated at this time. Interviews reveal that there was a staffing shortage, and residents were not being cared for in a timely manner. Deficiency cited on 9099-D.

Exit interview conducted, deficiency cited, and a copy of the report and appeal rights emailed to the administrator.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210907122144
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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Administrator will send a written commitment to CCLD outlining plans to maintain staffing levels appropriate to meet the needs of persons in care. Administrator will send a written commitment to CCLD to send updated Personnel Reports (LIC 500) monthly (due first of each month) to CCLD through 12/31/22. Administrator will send the (2) written commitments to CCLD by 9/15/22.
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Based on interviews, the facility did not ensure that adequate personal hygiene measures were in place to keep residents healthy which poses an immediate health and safety 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 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
09/07/2021 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20210907122144

FACILITY NAME:VILLAGE AT SYDNEY CREEK, THEFACILITY NUMBER:
405800577
ADMINISTRATOR:KIRK P KLOTTHORFACILITY TYPE:
740
ADDRESS:1234 LAUREL LANETELEPHONE:
(805) 543-2350
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:84CENSUS: 47DATE:
09/14/2022
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Kirk Klotthor, Executive Director/AdministratorTIME COMPLETED:
03:08 PM
ALLEGATION(S):
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Staff not supervising residents resulting in fall sustaining bruises
Staff left residents in soiled clothing for extended period of time resulting in rashes
Food service not provided to residents
INVESTIGATION FINDINGS:
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On 9/14/22 at 2:05 pm, Licensing Program Analyst (LPA) Chavez visited the facility to deliver final findings on a complaint investigation for the allegations listed above. LPA met with Kirk Klotthor, the facility administrator and explained the purpose of today’s visit.

On the allegation “Staff not supervising residents resulting in fall sustaining bruises,” the complainant’s concern was that “multiple residents have fallen sustaining bruises.” To investigate, LPA interviewed the administrator, staff, and witnesses, and reviewed records.

On 9/13/21 between 11:40 am and 1:54 pm, LPA interviewed Staff #1 (S1), Staff #5 (S5), Staff #6 (S6), and Staff #7 (S7). S1 says they have never seen residents with bruises from falls. S5 explains that there are “few falls” and that they have not seen bruises or skin tears on residents. S6 says “one to two months ago, there were 2-3 falls in a week with bruises and skin tears.” S7 says they have not seen an increase in falls.
Continued on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20210907122144
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: 09/14/2022
NARRATIVE
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On 9/17/21 at 3:07 pm, LPA interviewed Witness #1 (W1). W1 says their mother “has not had any falls, bruises, or skin tears while at the facility.”

On 8/11/22 between 10:50 am and 1:22 pm, LPA interviewed Witness #3 (W3) and Witness #4 (W4). W3 says “Mom has fallen a couple of times and both times, staff called W3 immediately.” W4 says “As people age, people fall.” W4 says “Staff know the residents who need assistance. My sister hasn’t had any falls.”

On 9/12/22, LPA reviewed the facility’s incident reports for falls between September 2020 and September 2021. There were twenty-five (25) falls, an average two (2) per month. Skin tears were noted on two of the incident reports.

Based on evidence obtained, the allegation “Staff not supervising residents resulting in fall sustaining bruises,” is deemed Unsubstantiated at this time. Interviews and records review indicate that residents did not have an unusually high number of falls prior to the complaint, and bruising was not a significant factor mentioned in interviews. There does not appear to be a lack of supervision at this time nor an excessive amount of falls given resident medical conditions.

On the allegation “Staff left residents in soiled clothing for extended period of time resulting in rashes,” the complainant’s concern was that “multiple residents are left in soiled diapers for up to 5 to 6 hours resulting in rashes.” To investigate, LPA interviewed the staff and witnesses.

On 9/17/21 at 3:07 pm, LPA interviewed W1. W1 says when their mother first arrived at the facility, W1 had to “train the staff on mom’s needs, i.e. changing her (diaper) regularly.” W1 says “now, she is being taken care of.”

On 9/13/21 between 12:20 pm and 12:30 pm, LPA interviewed Staff #4 (S4) and Staff #5 (S5). Both staff say they have never seen rashes on residents.

On 7/21/22 between 1:34 pm and 2:59 pm, LPA interviewed three staff. All three staff reported that some residents may have been left in soiled clothing for an extended period of time but did not indicate that residents received rashes from this. On 7/22/22 between 9:55 am and 10:45 am, LPA interviewed two staff. Staff say they hadn’t witnessed a problem. They say residents sometimes sit in soiled clothing for an extended period of time, however, no rashes were reported.

Continued on 9099-C

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20210907122144
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: 09/14/2022
NARRATIVE
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Based on the evidence obtained, the allegation “Staff left residents in soiled clothing for extended period of time resulting in rashes,” is deemed Unsubstantiated at this time. There is no evidence to suggest residents were acquiring rashes, however, the facility was cited on 8/25/22 for residents being left in soiled clothing for an extended period of time.

On the allegation “Food service not provided to residents,” the complainant was concerned that “residents are not provided dinner and are put to bed at 6:00 – 6:30 pm.” To investigate, LPA interviewed staff and witnesses.

On 9/13/21 between 12:08 pm and 1:54 pm, LPA interviewed Staff #3 (S3), S4, S5, S6, and S7. S3 says they “always make a sandwich in the kitchen and place it in the refrigerator, if a resident’s not there to eat.” S3 explains that there are extra snacks available to residents and that the common areas have water pitchers and coffee available on the kitchen counters. S3 says sometimes they feed residents in bed. S4, S5, S6, and S7 say that if a resident misses a meal, staff put the resident’s plate of food in the refrigerator with the resident’s name and date and say it is saved for the resident to eat later. Staff said that residents occasionally go to bed early, but that is not typical.

On 9/13/21 at 11:35 am, LPA toured the facility. LPA observed food service to be adequate. The kitchen was fully stocked with food, and staff were preparing and delivering meals to resident neighborhoods.

Based on the evidence obtained, the allegation “Food service not provided to residents,” is deemed Unsubstantiated at this time. Interviews indicate that staff are setting aside resident meals, if they are not available at meal time, and food is provided to residents.

Exit interview conducted and the report emailed to the administrator.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6