405801283-9-9-2021-29-AS-KBUY-C7CM8H-20210930092309

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801283
Report Date: 09/09/2021
Date Signed: 09/09/2021 12:55:21 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
04/12/2021 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20210412162127

FACILITY NAME:	ALDER HOUSE		FACILITY NUMBER:	405801283
ADMINISTRATOR:	TODD TOSE		FACILITY TYPE:	740
ADDRESS:	295 ALDER STREET		TELEPHONE:	(805) 489-1266
CITY:	ARROYO GRANDE	STATE: CA	ZIP CODE:	93420
CAPACITY:	32	CENSUS: 21	DATE:	09/09/2021
		UNANNOUNCED	TIME BEGAN:	10:54 AM
MET WITH:	Todd Tose/Licensee		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff handle residents in a rough manner.
Facility staff are verbally abusive to residents.
Medication not stored properly.
Facility staff are not properly trained.
Residents files are not complete.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 09/09/2021 at 11:00am, Licensing Program Analyst (LPA) Mark Jeffries conducted a COVID screening call to access the facility. No signs of COVID positive or symptoms according to the Licensee. At 11:05am LPA arrived at the facility, introduced himself and stated the reason for the visit was to deliver finial findings to this complaint.
As to the allegation of, “Facility staff handle residents in a rough manner.” Through interviews, documentation and observation it was determined that; on 04/22/2021 interviews of Residents 1-10 (R1-R10) of 20 total residents did not find any mistreatment or rough handling of the residents by the staff. All residents of the facility on this date who required a single or two person assist were interviewed. Documentation review of resident files and all submitted serious incident reports (SIR) [10 total SIRs] going back 12 months from the reported date (04/12/2021) of alleged complaint did not find any evidence resident injury or staff handling residents in a rough manor. All staff training was current and complete according to regulation requirements.
CONTINUED on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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-20210412162127

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: ALDER HOUSE	FACILITY NUMBER: 405801283
	VISIT DATE: 09/09/2021

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

LPA Jeffries and LPA Luong observed a two person assist and a single person assist and did not witness any safety concerns with either transfer. Due to lack of evidence, the allegation of, “Facility staff handle residents in a rough manner.” Is unsubstantiated, at this time.
As to the allegation of, “Facility staff are verbally abusive to residents.” Through interviews, documentation and observation it was determined that; on 04/22/2021 interviews of Residents 1-10 (R1-R10) of 20 total residents did not find any evidence that staff are verbally abusive to residents. Through interview with Administrator, it was found that on 04/11/2021 (day before complaint was filed), the facility chief was locked out of the facility in the AM hours of that day. There was a loud verbal interaction with the facility chief and one other employee which did not involve any residents and took place outside the facility. On 04/22/2021 from 8:45am to 1:00pm, LPAs Jeffries and Luong observed positive and appropriate interactions with staff and residents. Due to lack of evidence there was not enough evidence to support that facility staff were verbally abusive to residents, therefore, the allegation of “Facility staff are verbally abusive to residents.” Is unsubstantiated, at this time.
As to the allegation of, “Medication not stored properly.” Through interviews, audit, documentation and observation it was determined that, on 04/22/2021 interviews of Residents 1-10 (R1-R10) of 20 total residents did not find any problems with medication distribution, ordering or loss of medication. On 04/22/2021 at 9:04am LPA’s Jeffries and Luong conducted a facility tour with Administrator. LPAs observed a centrally located medication closet that was secured and within that secured closet was a secured medication cart. On 04/22/2021 at 10:51am LPA Jeffries conducted a medication audit of the facilities medication cart and reviewed Centrally Stored Medication Records and Medication Administration Records (MAR), LPA did not find any deficiencies or irregularities during this medication audit. LPA’s Jeffries and Luong did not observe any medication that was improperly stored. There was not enough evidence to support the allegation of medication was not stored properly, therefore, the allegation of, “Medication not stored properly.”, is unsubstantiated, at this time.

CONTINUED on LIC9099C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20210412162127

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: ALDER HOUSE	FACILITY NUMBER: 405801283
	VISIT DATE: 09/09/2021

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

As to the allegation of, “Facility staff are not properly trained.” Through interviews, documentation and observation it was determined that, on 04/22/2021 interviews of Residents 1-10 (R1-R10) of 20 total residents and Staff 2-5 (S2-S5) that residents were happy with the care and serviced that were rendered at this facility. On 04/22/2021 Administrator presented documentation of all staff training dates, hours of training and training flow chart using the RELIAS, Healthcare Training and Performance Solutions print outs. LPA reviewed RELIAS training for all direct care staff and current training. LPA was able to determine that all staff have adequate hours of training per Community Care Licensing Department regulations. On 04/22/2021, LPAs Jeffries and Luong observed positive and appropriate interactions with staff and residents. There was not enough evidence to support the allegation of facility staff are not properly trained, therefore the allegation of, “Facility staff are not properly trained.” Is unsubstantiated, at this time.

As to the allegation of, “Residents files are not complete.” Through interviews and documentation audit it was found that, on 04/22/2021 at 11:58pm, LPA Jeffries and Luong conducted a resident file audit of Residents 1-10 (R1-R10) of 20 total residents. LPA’s found that residents files were all complete with, but not limited to, admissions agreements, admission appraisals, facility appraisals, Physicians reports, emergency contact lists, personal right, personal items inventory and personal identification. Administrator stated that multiple administrators work to ensure residents files are complete and up to date with resident requirements. Due to completeness of resident’s files that were audited, there was not enough evidence to support that residents’ files are not complete, therefore, the allegation of, “Residents files are not complete.” is unsubstantiated, at this time.

Exit interview, report emailed

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3