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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801962
Report Date: 10/08/2021
Date Signed: 10/08/2021 01:55:03 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
10/01/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20211001151013
FACILITY NAME:SINGLETREE CARING HANDSFACILITY NUMBER:
405801962
ADMINISTRATOR:HERBERT SALAMANCAFACILITY TYPE:
740
ADDRESS:1789 SINGLETREE COURTTELEPHONE:
(805) 439-1119
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:6CENSUS: 3DATE:
10/08/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Miriam SalamancaTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff did not follow Covid-19 protocols
INVESTIGATION FINDINGS:
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Licensing Program Anaylst (LPA) De Leon conducted a 10-day Complaint visit to the facility above. LPA met with Back up to Administrator Miriam Salamanca and explained the purpose of the visit.

LPA entered the facility and was screened by staff for Covid Procedures. LPA requested which staff worked on 09/30/2021 during the day shift. The staff names and LIC 500 were provided to LPA. LPA interviewed Staff 1 (S1) and Staff 2 (S2).

On the allegation: Staff did not follow Covid-19 protocols. LPA interviewed witness which revealed that a witness visited the facility on 09/30/2021 and upon entry to the facility two staff were present and one staff was not wearing a mask. Staff interview revealed that staff
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: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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-20211001151013
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: SINGLETREE CARING HANDS
FACILITY NUMBER: 405801962
VISIT DATE: 10/08/2021
NARRATIVE
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 had come into the facility with a mask but the mask was not on, once the witness entered the staff put the mask on that was on the table. Based on the evidence the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, civil penalty assessed, copy of report and appeal rights emailed to Licensee/Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20211001151013
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: SINGLETREE CARING HANDS
FACILITY NUMBER: 405801962
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) 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 10/11/21.
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Based on interviews 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: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3