405800577-4-24-2024-29-AS-KBUY-D5PSAW-20240528134301

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 04/24/2024
Date Signed: 04/24/2024 01:12:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
04/17/2024 and conducted by Evaluator Erika Miller

COMPLAINT CONTROL NUMBER: 29-AS-20240417090505

FACILITY NAME:	VILLAGE AT SYDNEY CREEK, THE		FACILITY NUMBER:	405800577
ADMINISTRATOR:	KIRK P KLOTTHOR		FACILITY TYPE:	740
ADDRESS:	1234 LAUREL LANE		TELEPHONE:	(805) 543-2350
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	84	CENSUS: 57	DATE:	04/24/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	LIsa Hulse, VP of Operations		TIME COMPLETED:	01:22 PM

ALLEGATION(S):

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Staff does not make dangerous items inaccessible to the residents

INVESTIGATION FINDINGS:

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During the investigation, LPA toured the facility on April 24, 2024 from 11:00 a.m. to 12:00 p.m. LPA also obtained and reviewed relevant documents. LPA met with Lisa Hulse (Hulse), vice president of operations and explained the purpose of the visit.

On April 16, 2024, a witness visited the facility and observed an accessible bathroom cabinet in Neighborhood 1. The witness observed an unlocked cabinet that contained an uncovered toothbrush, toothpaste tube, and an aerosol can. On the second shelf the witness observed 2 electric shavers and an electric curling iron. Witness also observed a full gallon of hand soap on the bathroom counter. Hulse stated that the facility policy requires that items that may pose a danger must be made inaccessible to clients. Hulse stated that she has reminded staff of regulations. (Cont. 9099 C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

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-20240417090505

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
	VISIT DATE: 04/24/2024

NARRATIVE

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Hulse further stated that hand soap and hand lotion are not poisonous and that an electric razor is not dangerous. Hulse stated this she understands that it is best practice to make the items inaccessible.Hulse will be conducting a staff training to review relevant regulation and to discuss best practices moving forward.

At 11:30 a.m. LPA toured each communal bathroom and observed that each bathroom door was locked, and signage was posted that reminded staff that items that could be dangerous to residents must be locked.LPA did not observe any accessible items that could be dangerous to residents. Based on the LPA observation and interview, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC9099 (FAS) - (06/04)

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