405801720-7-22-2021-29-AS-KBUY-C56VJT-20210722162916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801720
Report Date: 07/22/2021
Date Signed: 07/22/2021 02:12:35 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
12/19/2019 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20191219144305

FACILITY NAME:	RESIDENCE, THE		FACILITY NUMBER:	405801720
ADMINISTRATOR:	MICHELLE MARCOS		FACILITY TYPE:	740
ADDRESS:	3220 CALLE MALVA		TELEPHONE:	(805) 596-0812
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	6	CENSUS: 4	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	01:12 PM
MET WITH:	Meynard Marcos, Licensee		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff is not properly transferring residents while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent Complaint visit to the facility above to deliver final findings in the complaint allegations. LPA met with Administrator/Licensee Meynard Marcos and explained the purpose of the visit.

During the investigation, LPA conducted interviews with staff on 12/30/2019 at 11:00 AM LPA interviewed Staff, Resident and witness. LPA reviewed records on 12/30/2019 at 2:20 PM, copy machine was not working and Administrator emailed copies requested to LPA on 12/31/2019. LPA reviewed records again on 07/22/2021 at 9:00am.

Continued 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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 5

Control Number 29-AS-20191219144305

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: RESIDENCE, THE	FACILITY NUMBER: 405801720
	VISIT DATE: 07/22/2021

NARRATIVE

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On the allegation: Staff is not properly transferring residents while in care. LPA interviewed Staff (S1, S2), Resident (R1), and witness (W1) and reviewed records. R1 and W1 interviews revealed that Staff 3 (S3) was not preforming transfers to the resident’s satisfaction. Records requested for training of transfers and hospice care were not provided to LPA to show S3 had any training specific to transfers. S2, R1 and W1 interviews revealed that S3 was not trying to be rough but had a language barrier in understating what the residents where saying and what they wanted or needed. 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 Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20191219144305

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: RESIDENCE, THE	FACILITY NUMBER: 405801720
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/29/2021 Section Cited CCR 87707(a)(2)(A)(1-6)	1 2 3 4 5 6 7	...activities of daily living, ...Communication skills (resident/staff relations);...End of life issues, including hospice. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will have all staff trained in Dementia residents, transfers, communication and hospice care. Administrator will provide hands on training with staff to determine if training on communication,
	8 9 10 11 12 13 14	Based on interviews and record review the licensee did not comply staff did not have proper training or communication when transferring resident which poses a potential safety risk to residents in care.	8 9 10 11 12 13 14	transfers and hospice care was understood by all staff and provide documentation to CCL.
	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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
12/19/2019 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20191219144305

FACILITY NAME:	RESIDENCE, THE		FACILITY NUMBER:	405801720
ADMINISTRATOR:	MICHELLE MARCOS		FACILITY TYPE:	740
ADDRESS:	3220 CALLE MALVA		TELEPHONE:	(805) 596-0812
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	6	CENSUS: 4	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	01:12 PM
MET WITH:	Meynard Marcos, Licensee		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
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5
6
7
8
9

Staff is not taking universal precautions as needed
Staff mishandles resident while in care

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20191219144305

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: RESIDENCE, THE	FACILITY NUMBER: 405801720
	VISIT DATE: 07/22/2021

NARRATIVE

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On the allegation: Staff is not taking universal precautions as needed. LPA interviewed staff 1 and 2 (S1, S2), Resident 1 (R1) and Witness 1 (W1) none of these interviews revealed the staff were not following universal precautions. LPA De Leon observed the facility to have hand washing soaps, paper towels, gloves, wipes and disinfectant. S1 and S2 stated staff are trained to change gloves after each resident and wash hands frequently. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Staff mishandles resident while in care. LPA interviewed S1, S2, R1 and W1 which revealed the staff was not mishandling the resident. R1 stated Staff 3 (S3) did not communicate to well with the residents and when he would do transfers it felt rough. R1 had feared falling. R1 was not scared of S3. R1 did not feel S3 was intentionally trying to be rough or that S3 was trying to hurt R1. R1 preferred S2 at the facility and wanted to be taken care of by S2. W1 did not feel S3 was trying to be rough with the resident and W1 revealed that it was a communication and training issue with S3’s transfers and safety. This evidence was addressed in this complaint in the first allegation. S1 and S2 interviews did not reveal any mishandling of residents in care. Based on the lack of evidence in the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, no deficiency cited, copy of report emailed to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5