<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800923
Report Date: 03/25/2022
Date Signed: 03/25/2022 02:41:58 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
03/23/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20220323093738
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: 4DATE:
03/25/2022
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator Lita LazoTIME COMPLETED:
02:47 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Masking protocols are not being followed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Anaylst (LPA) De Leon conducted a 10-day Complaint visit to the facility above. LPA met with Administrator Lita Lazo and explained the purpose of the visit.

LPA Requested a Staff Roster and Resident Roster. LPA conducted Interviews Staff 1 (S1) and Staff 2 (S2).

On the allegation: Masking protocols are not being followed. LPA interviewed crediable witness (W1) which revealed that W1 visited the facility on 03/16/2022 and a staff answered the door not wearing a mask. LPA observed at 2:10 pm on 03/25/2022 a staff in the facility not wearing a mask. Interview with staff 2 (S2) revealed S2 had just got done eating and did not put mask back on before LPA came to visit.
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: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
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 3
Control Number 29-AS-20220323093738
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: 03/25/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 S2 acknowledged S2 would wear a mask inside the facility at all times. Based on the evidence the allegation is deemed Substantiated at this time.

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

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220323093738
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: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2022
Section Cited
CCR
87468.1(a)(2)
1
2
3
4
5
6
7
87468.1(a)(2) Personal Rights of Residents in all Facilities:..To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to immediately implement mask wearing in the facility. Conduct training on Mask/Infectious Disease Prevention with all staff. Provide training records with all
8
9
10
11
12
13
14
Based on interviews the licensee did not ensure all staff were wearing face coverings in the facility which poses an immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
staff signatures to CCL by 03/28/2022.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3