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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801050
Report Date: 05/10/2022
Date Signed: 05/10/2022 03:36:52 PM

Substantiated


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
05/06/2022 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20220506115243
FACILITY NAME:FIVE CITIES RESIDENCEFACILITY NUMBER:
405801050
ADMINISTRATOR:PATACSIL, CAROLINA G.FACILITY TYPE:
740
ADDRESS:472 DIXSON STREETTELEPHONE:
(805) 489-3481
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:6CENSUS: DATE:
05/10/2022
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff are not following requirements to wear mask
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10-day Complaint visit to the facility. LPA met with Enos Patacsil Licensee/Administrator and explained the purpose of the visit.

LPA De Leon observed on 05/10/2022 at 3:00pm a caregiving staff with a mask worn around the neck instead of covering the nose and mouth in the room next to the kitchen with a resident present in the room.

On the allegation:Staff are not following requirements to wear mask. LPA De Leon recieved a statement that Witness 1 (W1) visited the facility on morning of 5/5/2022, W1 observed one caregiver not wearing a mask while wiping down the bathroom counter.
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: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
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-20220506115243
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: FIVE CITIES RESIDENCE
FACILITY NUMBER: 405801050
VISIT DATE: 05/10/2022
NARRATIVE
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Two other caregivers were present who were wearing masks. Based on the evidence this allegation is deemed Substantiated at the time.

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

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220506115243
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: FIVE CITIES RESIDENCE
FACILITY NUMBER: 405801050
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents...: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator agreed to hold infectious control training with masks requirments in the faciliy provide proof of training with staff signatures.
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Based on observation and W1 the licensee did not comply with regulation above 1 staff was present in the facility without a mask which poses an immediate Personal Rights risk to residents in care.
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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: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3