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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801953
Report Date: 12/16/2021
Date Signed: 12/16/2021 07:32:10 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
12/15/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20211215094704
FACILITY NAME:SCHWED ADULT FAMILY HOME 4FACILITY NUMBER:
405801953
ADMINISTRATOR:AMY L. HICKSFACILITY TYPE:
740
ADDRESS:411 APPALOOSA DRIVETELEPHONE:
(805) 221-5635
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 2DATE:
12/16/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Amy Hicks, AdministratorTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Residents have accessibility to items that pose a danger.
Facility is unsanitary/dirty.
Facility does not provide adequate food service/food storage.
Smoke detector was not working.
Facility does not have proper lighting.
Facility not allowing visitors.
Staff not wearing masks.
INVESTIGATION FINDINGS:
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Licensing Program Analyst's (LPA's) De Leon, Olson and LTCO Linda Beck conducted a 10 day complaint visit to the facility above. LPA's met with Staff Delaney Trujillo and explained the purpose of the visit. Staff called Administrator Amy Hicks and Amy arrived to the facility.

LPA's took a physical plant tour of the facility with staff and LTCO. LPA De Leon requested the following documents: LIC 500 staff roster, Staff Schedule, resident roster, LIC 602 for 2 resident in care, IPP from TCRC for 2 residents in care.

On the Allegation: Residents have accessibility to items that pose a danger. LPA's took a physical plant tour which revealed a broken piece of glass left out on cabinet, over the counter Cold and Flu night time syrup in unlocked cabinet in the kitchen, and sharp
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
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 9
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
12/15/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20211215094704

FACILITY NAME:SCHWED ADULT FAMILY HOME 4FACILITY NUMBER:
405801953
ADMINISTRATOR:AMY L. HICKSFACILITY TYPE:
740
ADDRESS:411 APPALOOSA DRIVETELEPHONE:
(805) 221-5635
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 2DATE:
12/16/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Amy Hicks, AdministratorTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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2
3
4
5
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8
9
Residents are not provided comfortable temperature.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst's (LPA's) De Leon, Olson and LTCO Linda Beck conducted a 10 day complaint visit to the facility above. LPA's met with Staff Delaney Trujillo and explained the purpose of the visit. Staff called Administrator Amy Hicks and Amy arrived to the facility.

LPA's took a physical plant tour of the facility with staff and LTCO. LPA De Leon requested the following documents: LIC 500 staff roster, Staff Schedule, resident roster, LIC 602 for 2 resident in care, IPP from TCRC for 2 residents in care.

On the Allegation: Residents are not provided comfortable temperature. LPA's toured the facility and the temperature met regulations requirements. The facility and resident bedrooms were warm on a cold and rainy day, beds had adequate blankets, cupboards
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 29-AS-20211215094704
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: SCHWED ADULT FAMILY HOME 4
FACILITY NUMBER: 405801953
VISIT DATE: 12/16/2021
NARRATIVE
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were stocked with additional linens and blankets for resident use. Based on the evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 29-AS-20211215094704
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: SCHWED ADULT FAMILY HOME 4
FACILITY NUMBER: 405801953
VISIT DATE: 12/16/2021
NARRATIVE
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knives in the kitchen sink. Witness 1's interview revealed knives and sharps in unlocked drawer in the kitchen accessible to residents in care. Staff removed the knifes and sharps from the drawer on LTCO. Bathroom near residents room 6 had unlocked cleaning products under the sink. Based on evidence this allegation is deemed Substantiated at this time.

On the Allegation: Facility is unsanitary/dirty. LPA's took a physical tour which revealed some areas of the facility were not kept clean, safe, sanitary and in good repair. LPA's observed the stove broiler area to be full of crumbs, dirt and grease, the kitchen cabinets were greasy to touch, cupboards had spilled food in them, the counter over the dishwasher had several nicks making it unsafe and in need of repair. The heating vents thorough out the facility were dirty with dust and debris, the kitchen walls were full of grease, discolored and in need of repainting, the hot water sink knob and over head light or fan is broken and in need of repair in the main bathroom, Bathroom between residents room 4 and 5 had a dirty mirror, bathtub, and cobwebs on the light fixture, the floor was discolored and stained, dining room floor was sticky, the light switches through out the facility are in need of cleaning and disinfecting, the carpeting in the hallway is ripped, frayed and can cause a trip hazard to residents in care as well as needing to be cleaned, the ramp to access the resident bedrooms is blocked by boxes, toys and clutter. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Facility does not provide adequate food service/food storage. LPA interviewed Witness 1 (W1) according to the interview the residents were without food and the food supply at the facility was very low. S1's interview revealed after W1's visit 12/13/2021 the facility went grocery shopping for needed food and supplies. S1 stated after W1's visit on 12/15/2021 and the concern for emergency food supplies and purchased several canned items, protein bars and water. W1's interview revealed several containers of unidentified material which appeared to be spoiled food in refrigerator without a date and requested the items to be discarded, Staff discarded all spoiled items. Staff acknowledged inadequate food supply on 12/13/2021 and would be shopping that evening. Staff said food was being delivered that afternoon. Based on the evidence this allegation is deemed Substantiated at this time.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 29-AS-20211215094704
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: SCHWED ADULT FAMILY HOME 4
FACILITY NUMBER: 405801953
VISIT DATE: 12/16/2021
NARRATIVE
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On the allegation: Smoke detector was not working. LPA's conducted a physical plant tour and checked each smoke detector in each room which revealed the smoke alarm was not working in bedroom 6. W1 visited the facility on 12/13/2021 and Resident 1's (R1's) smoke detector right out side the bedrooms was loose and not working when tested. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Facility does not have proper lighting. LPA's conducted a physical plant tour of the facility which revealed room 6 had no lighting, the hallway light near room 4 and 5 was not working, several light switches did not work or have lighting to check if the switch was working, several lights had light bulbs not working. W1 interview revealed resident 1 (R1) was sitting in room with no lamp or source of light available. Staff had brought a working lamp into the room prior to LPA visit. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: Facility not allowing visitors. LPA's witnessed a hand written sign hung on the door stating no visitors allowed. W1 visited the facility on 12/13/2021 and 12/15/2021 and the same sign was posted. LPA De Leon explained to S1 the sign needed to be taken down and the residents were allowed visitation inside the facility. S1 immediately took sign down. Based on the evidence this allegation is deemed substantiated at this time.

On the allegation: Staff not wearing masks. LPA's visited the facility on 12/16/2021 and neither staff 1 or staff 2 had a mask on. S1 pulled up mask after answering the front door when LPA's arrived. S1 masks was not fitting properly and kept falling down under S1's nose most of the visit. S2 never had a mask on thorough out the LPA's visit. W1's interviewed revealed on 12/13/2021 that staff 1 was not wearing a mask the whole visit with residents present. S1's interview revealed S1 was not wearing a mask on W1's visit 12/13/2021. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview, deficiencies cited, civil penalty assessed, copy of report and appeal rights emailed to Administrator.




SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 29-AS-20211215094704
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: SCHWED ADULT FAMILY HOME 4
FACILITY NUMBER: 405801953
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2021
Section Cited
CCR
87309(a)
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7
(a)...,cleaning solutions,...and other items which could pose a danger if readily available to clients shall be... inaccessible to clients. This requirement was not met as evidenced by:
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Administrator agreed to clean the facility and make all dangerous items inaccessible to residents in care.
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Based on observation the licensee did comply with the above as broken glass, cold/flu syrup, and cleaning products were accessible which poses an immediate Safety risk to residents in care.
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Type A
12/17/2021
Section Cited
CCR
87555(A)
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(a)...quality and in the quantity necessary to meet the needs of the residents...All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidneced by:
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Administrator agreed to clean kitchen/dining areas and buy any needed groceries and supplies and maintain the food supply 7 days a week 24 hours a day as well as emergency food and water.
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Based on Observation the licensee did not comply with the above, the facility had spoiled food and inadequate amount of food for residents in care which poses an immediate health and safety risk to reisdents 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 29-AS-20211215094704
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: SCHWED ADULT FAMILY HOME 4
FACILITY NUMBER: 405801953
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2021
Section Cited
CCR
87203
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All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidneced by:
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Administrator agreed to test and make sure all smoke alrams are working thorugh out the facility in every room, buy backup batteries and purchase new alarms if not working with new batteries.
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Based on observation the licensee did not comply with the above, Two of the smoke alarms in the facility were not working which poses an immedate Health and safety risk to residents in care.
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Type A
12/17/2021
Section Cited
CCR
87468.1(a)(2)
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(a) Residents...all of the following personal rights:(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 staff training on infections control procedures and mask wearing, provide a cover page along with staff signatures of trianing to CCL.
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Based on observation and interview the licensee did not comply with the above, Staff wear not wearing masks in the facility which poses an immediate health and safety risk to reisdents 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 29-AS-20211215094704
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: SCHWED ADULT FAMILY HOME 4
FACILITY NUMBER: 405801953
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2021
Section Cited
CCR
87303(a)
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7
(a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidenced by:
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Administrator agreed to clean and disinfect the entire facility and provide a video or photos of the cleaned facility to CCL.
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Based on Observations and interviews the licensee did not comply with the above, Facility was not clean, not safe and not sanitary which poses a potential health and safety risk to residents in care.
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Type B
12/23/2021
Section Cited
CCR
87303(d)
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(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement was not met as evidenced by:
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Administrator agreed to put lamps in dimely lit rooms and purchased new light bulbs for several lights in the facility that were not working. Send photos of working lights in everyroom to CCL.
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Based on observation the licensee did not comply with the above, Facility had several lights not working, burned out light bulbs or no lamps in the room which poses a potential safety 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 29-AS-20211215094704
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: SCHWED ADULT FAMILY HOME 4
FACILITY NUMBER: 405801953
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited
CCR
87468.1(a)(11)
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2
3
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5
6
7
(11)To have their visitors,...permitted to visit privately during reasonable hours and without prior notice,...
This requirement was not met as evidenced by:
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5
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7
Administrator agreed to take down the no visiting sign and hand new visitor signs on the front door of the facility, take a picture and send to CCL.
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14
Based on observation the licensee did not comply with the above, a sign was on the door not allowing visitors in the facility which poses a potential personal rights risk to residents in care.
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10
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7
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7
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
LIC9099 (FAS) - (06/04)
Page: 9 of 9