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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802300
Report Date: 09/22/2023
Date Signed: 09/22/2023 03:49:24 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
09/21/2023 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20230921143833
FACILITY NAME:HOPE ASSISTED LIVINGFACILITY NUMBER:
405802300
ADMINISTRATOR:CASTANIAGA, JANELYNFACILITY TYPE:
740
ADDRESS:1023 SLEEPY HOLLOWTELEPHONE:
(805) 717-4578
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 6DATE:
09/22/2023
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Licensee / Janelyn Castaniaga TIME COMPLETED:
01:49 PM
ALLEGATION(S):
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Staff were not present at the facility for an extended period of time.

INVESTIGATION FINDINGS:
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 At 10:00am on 09/22/2023, Licensing Program Analyst (LPA) Jeffries arrived at the facility to conduct the initial investigation to the allegation above to this complaint. LPA met with Licensee Janelyn Castaniaga, announced who he was and the reason for the visit.
As to the allegation of, "Staff were not present at the facility for an extended period of time." It was alleged that on 09/20/2023 at approximately 5:00 PM, residents of the facility were discovered be alone in the facility when staff were not present. A reliable witness (W1) reported that upon entering the facility, they searched for staff and staff were not present. W1 searched each room of the facility and discovered that five Residents (R2-R6) were left in their beds when there were no staff present at the facility. On 09/22/2023, at 10:41am, LPA Jeffries interview facility Licensee/Administrator, Licensee stated that Staff 1 (S1) stated that they left the facility to go on a personal errand to Walmart and did not notify other caregivers, resulting in staff not being present at the facility. At 11:08am on 09/22/2023, LPA Jeffries interviewed S1, S1 stated that, in the late afternoon (approximately 5:00pm), S1 left the facility and went to Walmart for personal medical supplies. CONTINUED on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
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-20230921143833
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: HOPE ASSISTED LIVING
FACILITY NUMBER: 405802300
VISIT DATE: 09/22/2023
NARRATIVE
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When S1 returned to the facility there was a Paramedic and R1 at the facility. Paramedic was retuning R1 from the hospital emergency room. LPA reviewed R1-R6 LIC602 (Physician Reports) which indicated that 4 of 6 residents have a diagnosis of Dementia/Alzheimer disease and two residents have mild cognitive impairment. Based on admission, interviews, documentation and a creditable witness, the allegation of, "Staff were not present at the facility for an extended period of time" and is substantiated at this time.

Exit interview, citation issued, fine assessed, report read, report and appeal rights provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230921143833
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: HOPE ASSISTED LIVING
FACILITY NUMBER: 405802300
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/25/2023
Section Cited
CCR
87464(f)(1)
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(f)Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews, admission, documentation and creditable
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Licensee agreed to review regulation 87464, write a statement of understanding on how the facility will prevent this from occurring again, provide an LIC 500 for staff, submit an incident report to the CCL and notify all residents responsible parties of the incident.
Civil Penalty Assessed.
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witness the licensee did not comply with the regulation above in that 5 residents were left alone without care and supervision for up to an hour which posed 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: Mark JeffriesTELEPHONE: (805)562-0400
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3