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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801985
Report Date: 04/28/2022
Date Signed: 04/28/2022 01:49:00 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
04/25/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220425085516
FACILITY NAME:PASO SENIOR CAREFACILITY NUMBER:
405801985
ADMINISTRATOR:MEYNARD MARCOSFACILITY TYPE:
740
ADDRESS:197 CARDINAL WAYTELEPHONE:
(805) 835-4762
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 6DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:May Cabello, CaregiverTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not following face mask requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced 10-day complaint investigation visit to the facility above. LPA met with May Cabello, Staff, and explained the purpose of the visit.

LPA toured the facility at 12:30 and observed 2 staff wearing their masks properly. LPA interviewed Maynard Marcos, Administrator over the telephone. Administrator stated that most staff wear masks but sometimes they forget and we have to remind them. LPA interviewed 2 staff regarding the allegation. Staff (S1) interview revealed it may have been them. S1 was alone in the kitchen sorting mail and took off mask to breath. Staff (S2) stated the staff are always wearing masks, it's protocol. A credible witness (W1) stated on 4/22/2022, W1 observed one caregiver not wearing a mask, and did not have it on their person. Based on credible witness statement and interviews, this allegation is deemed Substantiated at this time.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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-20220425085516
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: PASO SENIOR CARE
FACILITY NUMBER: 405801985
VISIT DATE: 04/28/2022
NARRATIVE
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The facility failed to protect the personal rights of residents in care to be able to receive safe and healthful accommodations, in that the facility staff failed to wear face coverings properly while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Licensee/Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220425085516
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: PASO SENIOR CARE
FACILITY NUMBER: 405801985
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited
CCR
87468.1
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87468.1 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 has agreed to immediately notify all staff to wear masks at all times in the facility. Administrator agreed to hold training with all staff about proper mask-wearing and COVID-19 prevention protocol, and provide training records to CCL by 4/29/2022.
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Based on credible witness observation and interviews, the licensee did not ensure staff were wearing face masks in the facility, which poses an immediate health, safety and personal rights risk to residents in care.
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CCR
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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: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3