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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801600
Report Date: 05/17/2022
Date Signed: 05/17/2022 12:35:29 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
05/13/2022 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20220513111806
FACILITY NAME:INGLESIDE ASSISTED LIVING INC.FACILITY NUMBER:
405801600
ADMINISTRATOR:WILLIAM VAUGHNFACILITY TYPE:
740
ADDRESS:10630 WEST FRONT ROADTELEPHONE:
(805) 460-6541
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:16CENSUS: DATE:
05/17/2022
UNANNOUNCEDTIME BEGAN:
11:42 AM
MET WITH:Nikole Daugherty/AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff not wearing a mask
INVESTIGATION FINDINGS:
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 At 12:15pm on 05/17/2022, Licensing Program Analyst (LPA) Jeffries conducted a 10-day Complaint visit to the facility above. LPA met with Administrator Nikole Daugherty and explained the purpose of the visit.
LPA Requested a Staff Roster and Resident Roster. Interviewed Staff 1 (S1) and Staff 2 (S2).

On the allegation: Staff are not following masking requirements. LPA interviewed credible witness (W1) which revealed that W1 visited the facility on 5/12/2022 at approximately 11:00am. W1 observed a cook in the kitchen not wearing a mask. Additionally at 12:10pm 05/17/2022, LPA observed male cook enter and exit the facility in the kitchen area not wearing a mask. Based on the evidence the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights provied to Licensee/Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
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 2
Control Number 29-AS-20220513111806
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: INGLESIDE ASSISTED LIVING INC.
FACILITY NUMBER: 405801600
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2022
Section Cited
CCR
87468.1(a)(2)
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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:
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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
staff signatures to CCL by 05/31/2022.
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Based on interviews and observation 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.
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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: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2