405801962-6-13-2022-29-AS-KBUY-CG8SUY-20220711141154

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801962
Report Date: 06/13/2022
Date Signed: 06/13/2022 03:01:26 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
06/07/2022 and conducted by Evaluator Mark Jeffries

COMPLAINT CONTROL NUMBER: 29-AS-20220607161104

FACILITY NAME:	SINGLETREE CARING HANDS		FACILITY NUMBER:	405801962
ADMINISTRATOR:	HERBERT SALAMANCA		FACILITY TYPE:	740
ADDRESS:	1789 SINGLETREE COURT		TELEPHONE:	(805) 439-1119
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93405
CAPACITY:	6	CENSUS: 3	DATE:	06/13/2022
		UNANNOUNCED	TIME BEGAN:	01:29 PM
MET WITH:	Nancy Naguit / Caregiver		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility does not have an emergency water supply.

INVESTIGATION FINDINGS:

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At 1:30pm on 06/13/2022, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct the annual 10 day investigation to the allegation above. LPA met with Caregiver Nancy Naguily (NN). At 1:38pm on 06/13/2022, NN contacted Administrator Herbert Salamanca by phone and Administrator authorized to LPA for NN to sign the complaint as Administrator could not come to the facility at this time.
As to the allegation of, "Facility does not have an emergency water supply." It was discovered through interviews, documentation, photographs, admission and observation of no emergency water present at the facility, that the facility did not have any emergency supply of water. At 2:08pm on 06/13/2022, LPA reviewed and copied the facilities emergency disaster plan (EDP). The EDP section, "Shelter In Place Procedures" (page 4 of 9) paragraph two states, "Specify plan for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency disaster, including, but not limited to, a short-term or long-term power failure. Additionally, hand written in the box below states, "Water we should have @ least 20 to 25 portable water plus all drink & juices in the storage room & shelf." At 2:21pm, on 06/13/2022, LPA CONTINUED on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

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 3

Control Number 29-AS-20220607161104

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: 06/13/2022

NARRATIVE

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observed and photographed emergency supply shelf in garage, identified by NN, that there were no water, drinks or juices on the supply shelf. LPA asked if there were additional areas of emergency storage and NN state, "that is the only one." Administrator and NN both stated that there was no emergency supply water at the facility, EDP states there was to be a supply of 20 to 25 portable waters plus drinks and juices in storage or shelf that were not there. Based on the admissions, observations, documentation of the EDP and photographs, the allegation of, " Facility does not have an emergency water supply." is substantiated at this time.

Exit interview, citation issued, repot signed and copy provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 29-AS-20220607161104

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: 06/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/20/2022 Section Cited HSC 1569.695(a)(2)	1 2 3 4 5 6 7	1569.695, a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include... (2) Plans for the facility to be self-reliant for a period of not less than 72 ... including water... is not available, the facility	1 2 3 4 5 6 7	Administrator will secure at a minimum of the stated amount of emergency water supply from the facilities EDP. Administrator will provided photographic evidence of water at the facility posted on the emergency supply shelf in the facility garage as stated on the EDP by 06/20/2022.
	8 9 10 11 12 13 14	shall have a plan and supplies available to provide alternative resources during an outage. This requirement was not met by admission, observation and documentation, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Email photographic proof to mark. jeffries@dir.ca.gov by 06/20/2022.
	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: Mark Jeffries	TELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

LIC9099 (FAS) - (06/04)

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