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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800987
Report Date: 10/10/2024
Date Signed: 10/10/2024 12:26:29 PM

Unsubstantiated


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
03/01/2024 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20240301111042
FACILITY NAME:IRENE'S BOARD & CAREFACILITY NUMBER:
405800987
ADMINISTRATOR:ANGELITA O. MARAVILLASFACILITY TYPE:
740
ADDRESS:220 VIA PROMESATELEPHONE:
(805) 227-0276
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 4DATE:
10/10/2024
UNANNOUNCEDTIME BEGAN:
07:00 AM
MET WITH:Licensee/Administrator, Angelita MaravillasTIME COMPLETED:
01:08 PM
ALLEGATION(S):
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Staff do not provide a comfortable temperature for the residents.
Staff do not know to operate a Hoyer lift.
Staff forced the residents to remain in recliners while in care.
Staff did not address a resident's change in medical condition.
Staff are limiting the residents’ activities.
Staff are being forceful with residents.
INVESTIGATION FINDINGS:
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At 7:00 am on 10/10/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to conduct a new complaint investigation visit, and issue final finding on two separate older complaints. LPA met with Licensee/Administrator, Angelita Maravillas, announced who he is and the reasons for the visit.

As to the allegation of, “Staff do not provide a comfortable temperature for the residents.” It was alleged that residents have complained about being cold in their rooms; It was discovered by observations and interviews that Facilities temperature reading on 03/01/2024 at 2:15pm was 73 degrees Fahrenheit, and on 02/20/2019 at 11:10AM read at 71 degrees Fahrenheit and on 01/16/2019 at 10:30AM temperature read 76 degrees Fahrenheit. On 03/01/2024, LPA Jeffries interviewed Resident 1(R1) who indicated that the facility temperatures is “just fine” and has never a problem with facility temperature. On 03/01/2024 LPA Jeffries interviewed R2, and R3, who both stated that they didn’t have any problems with temperature at the facility. On 03/08/2024.
CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
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-20240301111042
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: IRENE'S BOARD & CARE
FACILITY NUMBER: 405800987
VISIT DATE: 10/10/2024
NARRATIVE
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LPA Jeffries conducted interview with S1, who stated that the heater and Air Conditioner are both in good working order, and staff will adjust thermostat per Residents requests. At this time, there is not enough evidence to support the allegation of, “Staff do not provide a comfortable temperature for residents.” and is unsubstantiated at this time.
As to the allegations of, “Staff do not know how to operate a Hoyer Lift.” And “Staff are being forceful with residents.” It was alleged that, on 02/29/2024 resident 1 (R1) was incorrectly positioned in the harness when being lifted and forceful feeding and drinking. It was discovered through documentation, observations, and interviews, on 02/02/2024, LPA conducted interviews with S1 and S2 who both stated that they are current on 20 or more hours of annual training, including 8 hours of dementia specific training. On 03/08/2024, LPA observed training records for in-service Hoyer Lift Training for S1 on 11/01/2016, and S2 on 12/02/2018. S1 stated that they have more than 10 years’ experience in care giving with this population, and S2 stated they have more than 25 years’ experience in care giving with this population. On 03/08/2024, LPA Jeffries attempted to interview R1, R2, R3, and R4 all were unable to cognitively answer questions about staff care and staff assisted transfers. On 02/02/2024, LPA Jeffries observed Residents 1-2 being assisted from living room by S2 with no issues. On 02/02/2024, LPA conducted an interview with Administrator, Angelita Maravillas, who is currently a licensed Registered Nurse, who conducts in-house training for all staff, who stated all staff are experienced and trained. At this time there in not enough evidence to support the allegations of, “Staff are not properly trained.” and.” And “Staff are being forceful with residents.” both are unsubstantiated at this time.
As to the allegation of, “Staff did not address a resident's change in medical condition.” It was alleged that, unidentified male Resident showed signs of being depressed and was not communicated to family. It was discovered through documentation and interviews that on 03/08/2024, LPA Jeffries interviewed R1 and R4 both males that are currently residing at the facility; Both R1 and R4 were able to provide very basic answers to questions, due to cognitive impairments. Both R1 and R4 stated that the facility temperature was comfortable with no issues but could not state if they were happy or depressed. On 03/08/2024 LPA conducted interview with Administrator, who stated due to their diagnosis and medication, both R1 and R4 show decreasing abilities in Activities of Daily Living (ADL’s), Administrator stated that both their Physicians and Family Member are aware of declining. On 03/08/2024, LPA Jeffries reviewed R1 and R4 Physician Report (LIC602) and Centrally Stored Medication Records (CSMR) and verified Administrators interview. At this time there is not enough evidence to support the allegation of, “Staff did not address a resident’s change in condition.” And is unsubstantiated at this time.
CONTINUED on LIC9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20240301111042
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: IRENE'S BOARD & CARE
FACILITY NUMBER: 405800987
VISIT DATE: 10/10/2024
NARRATIVE
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As to the allegations of, “Staff are limiting the residents’ activities.” and “Staff forced the residents to remain in recliners while in care.” It was alleged that, there were multiple instances of staff forcing residents to remain in their recliners, and staff turning off residents’ televisions without consent. It was discovered through interviews. On 03/08/2024, LPA Jeffries conducted interviews with 4 of 6 Residents. R1, R3, and R4 were not able to answer questions pertaining to activities and television schedules. R1, R2, R3, and R4 all stated “yes” when asked if they could move to their rooms if they wanted, and only R2 stated that staff will sometimes turn the television off in their room before they fall asleep. On 02/02/2024, LPA Jeffries observed Residents 1-2 being assisted from living room by S2 with no issues. 03/08/2024, LPA conducted interview with S1, who stated that they will leave the television on in the resident’s room until the resident falls asleep or at their request. LPA noted that R2 occupies a double occupancy room. At this time there in not enough evidence to support the allegation of, “Staff are limiting the residents’ activities.” and “Staff forced the residents to remain in recliners while in care.” and both are unsubstantiated at this time.

Exit interview, report read, and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3