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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800923
Report Date: 03/29/2021
Date Signed: 03/29/2021 03:34:18 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
08/26/2020 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20200826104510
FACILITY NAME:SOUTHBAY MAXI CAREFACILITY NUMBER:
405800923
ADMINISTRATOR:LITA C. LAZOFACILITY TYPE:
740
ADDRESS:1410 13TH STREETTELEPHONE:
(805) 528-1725
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:6CENSUS: 3DATE:
03/29/2021
UNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Lita Lazo, Licensee/AdministratorTIME COMPLETED:
02:37 PM
ALLEGATION(S):
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Staff did not allow resident to receive medical care
INVESTIGATION FINDINGS:
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On 3/29/2021 at 2:23 pm, Licensing Program Analyst (LPA) Chavez conducted an unannounced meeting to discuss final findings on the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint final findings meeting was conducted through phone chat with Lita Lazo, Facility Licensee/Administrator.

On the allegation “Staff did not allow resident to receive medical care,” the complainant’s concern was that Resident #1 (R1) would not get the care needed because the licensee refused to allow home health into the facility. To investigate this allegation, LPA interviewed the complainant, facility licensee, and witnesses; and reviewed facility records.

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: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
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 3
Control Number 29-AS-20200826104510
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: SOUTHBAY MAXI CARE
FACILITY NUMBER: 405800923
VISIT DATE: 03/29/2021
NARRATIVE
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The licensee states that R1 was admitted into the facility on 8/21/2020 with a negative COVID-19 test, and to ensure R1 was completely clear of the virus, the licensee placed R1 in quarantine for 14 days. In interviews with the licensee and home health workers, it was determined that R1’s physician had orders for home health care at the time R1 was admitted to the facility. Licensee confirmed that on 8/26/2020 she refused home health workers from entering the facility due to the “COVID situation.” The facility had no cases of COVID-19, and essential workers were authorized to enter the facility. Home health services were not discontinued until 8/27/2020 per orders from R1’s physician.

Based on this investigation, LPA found sufficient evidence to support that R1 did not receive needed medical care. As a result, regarding the allegation that, “Staff did not allow resident to receive medical care”, the finding is Substantiated. The facility did not ensure that R1 was treated per physician orders thereby violating “a resident’s personal right to be accorded safe and healthful accommodations” in accordance with Title 22, California Code of Regulations. The deficiency will be cited on an LIC 9099-D.

At 2:37 pm, an exit interview was conducted with Lita Lazo and an electronic copy of the report was faxed for signature and to be returned to LPA. A copy of the appeal rights was also included.

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

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20200826104510
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: SOUTHBAY MAXI CARE
FACILITY NUMBER: 405800923
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/05/2021
Section Cited
CCR
87611(e)
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87611 General Requirements for Allowable Health Conditions
(e) In addition to Sections 87465(a) and 87464(d) the licensee shall ensure that the resident is cared for in accordance with the physician's orders and that the resident's medical needs are met. This requirement was not met as evidenced by:
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Administrator has agreed to immediately change the facility’s visitor plan to allow essential visitors. Administrator will read and train staff on PINs 20-23-ASC, 20-38-ASC, 20-46-ASC, and 21-17-ASC. Administrator will send a sign-in sheet to CCLD showing completion of trainings with signatures of all staff trained, dated, and who performed the training. Administrator will send signed, dated training sheet to LPA by 4/05/2021.
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Based on interviews and records review, the licensee/administrator did not comply with the regulation above, the licensee did not ensure that a resident was treated per physician orders.
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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: 03/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3