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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800577
Report Date: 08/02/2021
Date Signed: 08/02/2021 05:04:10 PM



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
12/06/2019 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20191206084044
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: DATE:
08/02/2021
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Lisa Hulse, VP of OperationsTIME COMPLETED:
05:21 PM
ALLEGATION(S):
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Staff made inappropriate comments towards resident(s) in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Lon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Lisa Hulse, VP of Operations and explained the purpose of the visit.

During the investigation, LPA conducted interviews with staff on 07/28/2021 at 10:25 am, 11:11 am, 11:43 am, 12:51 pm, 1:41 pm, 4:01 pm, and on 07/29/2021 at 1:57 PM. LPA conducted interviews with witnesses on 07/29/2021 at 3:32 pm, 3:48 pm, 4:03 pm, 4:08 pm and 08/02/2021 at 12:47 pm. LPA reviewed records on 07/30/2021 at 5:00 pm and 08/02/2021 at 4:45 pm took tour of the facility Kitchen and food supply. LPA was unable to conducted interviews with residents due to cognitive awareness in the memory care (MC) facility.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
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-20191206084044
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: 08/02/2021
NARRATIVE
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On the allegation: Staff made inappropriate comments towards resident(s) in care. LPA interviewed staff 1 (S1), Staff 2 (S2), Staff 3 (S3), Staff 5 (S5) and Staff 6 (S6) revealed that some staff persons did talk to residents and say things that were not appropriate to say to or in front of a resident. S6 thought the staff’s intent was not to be harmful. S3, S5 and S6 revealed it may have been a culture issue as sometimes other languages were spoken in front of residents and it was not appropriate for the work place or the residents because some of the residents could not understand what was being said so it seemed rude to do in front of them. S6 revealed a staff was joking but that she didn’t laugh or come across to others that way so if you didn’t know the staff personally it might have come across as inappropriate. Based on the evidence this allegation is deemed substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to facility.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 29-AS-20191206084044
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: 08/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2021
Section Cited
CCR
87468.1(a)(1)
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...(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by:
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Administrator agreed to hold staff training on personal rights, communication with staff and residents, give staff examples of appropriate/inappropriate language in the work place and provide proof
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Based on interviews with staff the licensee did not comply with the regulations above as staff made inappropriate comments to resident in care, which poses an immediate personal rights risk to resident in care.
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of trainings topics with staff signatures to CCL.
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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: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 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
12/06/2019 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20191206084044

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: DATE:
08/02/2021
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Lisa Hulse, VP of OperationsTIME COMPLETED:
05:21 PM
ALLEGATION(S):
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Staff hit resident(s) in care
Staff handled resident(s) in a rough manner
Staff failed to assist resident in a timely manner after a fall
Staff threatened resident in care
Staff withheld food from resident(s) in care
Staff failed to ensure resident's shower water was a comfortable temperature
Staff assisted resident in an unsafe manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Lon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Lisa Hulse, VP of Operations and explained the purpose of the visit.


During the investigation, LPA conducted interviews with staff on 07/28/2021 at 10:25 am, 11:11 am, 11:43 am, 12:51 pm, 1:41 pm, 4:01 pm, and on 07/29/2021 at 1:57 PM. LPA conducted interviews with witnesses on 07/29/2021 at 3:32 pm, 3:48 pm, 4:03 pm, 4:08 pm. LPA reviewed records on 07/30/2021 at 5:00 pm and 08/02/2021 at 4:45 pm took tour of the facility Kitchen and food supply. LPA was unable to conducted interviews with residents due to cognitive awareness in the memory care (MC) facility.
Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20191206084044
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: 08/02/2021
NARRATIVE
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On the allegation: Staff hit resident (s) in care. Based off Interviews with Staff 1 (S1), Staff 2 (S2), Staff 3 (S3), Staff 4 (S4), Staff 5 (S5), Staff 6 (S6) and Witness 1 (W1), Witness 2 (W2), Witness 3 (W3), Witness 4 (W4), and Witness 5 (W5), no hitting of residents by staff was ever observed. S1-S7 were trained to report any incident of abuse and if witnessed they would have reported the incident. W1-W5 stated they had never observed residents being hit by staff at any visits they made to the facility. Due to a lack of evidence this allegation is deemed unsubstantiated at this time.

On the allegation: Staff handled resident(s) in a rough manner. LPA interviewed several staff , S1-S7 did not witness any accounts of staff handling residents roughly. Witnesses W1-W5 have never seen staff handle any resident in a rough manner. S1-S7 stated they are trained correctly to handle residents with proper care and trained techniques are used to provide added safety along with 2- person assist when needed. Due to the lack of evidence this allegation is deemed unsubstantiated at this time.

On the allegation: Staff failed to assist resident in a timely manner after a fall. LPA interviewed S1-S7 and W1-W5 all interviews revealed falls do happen, but staff respond quickly to falls, medication-technicians (MT) are called immediately to assess, MT call 911 when needed and responsible parties are notified promptly. S1-S7 stated fall procedures are followed and it is all done in a timely matter. Due to the lack of evidence the allegation is deemed unsubstantiated at this time.

On the allegation: Staff threatened resident in care. All interviews conducted with S1-S7 and W1-W5 did not reveal any staff were threatening to any residents in care. S1-S7 interviews revealed that staff were caring and did their jobs well. W1-W5 said staff that they came across during visits to the facility were doing a great job caring and meeting the needs of the residents. Based on the lack of evidence this allegation is deemed unsubstantiated at this time.

Continued 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20191206084044
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: 08/02/2021
NARRATIVE
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On the allegation: Staff withheld food from resident(s) in care. Based on interviews conducted with S1-S7 the facility has plenty of food to feed residents, residents are given choices in meals, some residents are on a special diet due to being diabetic or lactose intolerant as well as needing food pureed or cut up into smaller chunks for swallowing. S2, S3, S6 stated the only time a meal would be taken away is if the resident was on a special diet and handed the wrong meal, but it would be replaced with another meal they could eat. S3 and S7 interview revealed if residents wanted to sleep or just didn’t want to eat at that time the staff would have the food wrapped to be given to them when they were ready. None of the interviews conducted revealed food was being withheld from residents. On 08/02/2021 at 4:45 pm, LPA toured the facility kitchen, observed the food supply, reviewed the menu records and choices available to the residents, everything was within regulations requirements. Based on the lack of evidence in this allegation it is deemed unsubstantiated at this time.

On the allegation: Staff failed to ensure resident's shower water was a comfortable temperature. Interviews with S1-S7 all stated the PCA would run the water first, then check it before putting the resident inside the shower. S1, S4 and S5 stated they would ask the resident to check it with a hand or foot before putting their full body in the water and if a resident needed water adjusted staff would do that for them. W1-W5 stated they never observed showers being too hot or cold in temperature and none of the residents ever stated to W1-W5 that their shower or water temperature was a problem. Due to the lack of evidence this allegation is deemed unsubstantiated at this time.

On the allegation: Staff assisted resident in an unsafe manner. The interviews with S1-S7 revealed staff were trained to assist residents in the safest manner, staff would ask for help when needed, and 2-person assists were conducted when needed. W1-W5 revealed no issues with staff assisting residents and observed it done safely when they were in the facility. Due to the lack of evidence this allegation is deemed unsubstantiated at this time.

Exit interview conducted and copy of report emailed to Facility.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6