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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802555
Report Date: 07/08/2021
Date Signed: 07/08/2021 06:46:14 PM

Unsubstantiated


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
07/02/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210702090846
FACILITY NAME:SOUTHLAND HOMEFACILITY NUMBER:
405802555
ADMINISTRATOR:VALDEZ, KATHYRINEFACILITY TYPE:
740
ADDRESS:804 SOUTHLAND STTELEPHONE:
(805) 929-5096
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:4CENSUS: 3DATE:
07/08/2021
UNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Kathyrine Valdez, LVNTIME COMPLETED:
01:56 PM
ALLEGATION(S):
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Facility interfered with resident receiving mail.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit at the facility above on 07/08/2021 at 10:00am. LPA met with Kathyrine Valdez, LVN back up to Administrator at the facility and explained the purpose of the visit.

LPA requested the following records: Staff schedule for week of 06/19/2021- 06/25/2021, Staff roster with phone numbers, Resident 1 (R1) emergency information and contacts sheet, threee residents personal property and valuables records, Visitor sign in and out log for 05/19/2021-07/08/2021, Copy of paperwork that was served to R1 on 05/25/2021, Copy of R1's Temporary Conservator paperwork.

LPA reviewed all records and conducted interviews with facility staff and witnesses.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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 2
Control Number 29-AS-20210702090846
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: SOUTHLAND HOME
FACILITY NUMBER: 405802555
VISIT DATE: 07/08/2021
NARRATIVE
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On the allegation: Facility interfered with resident receiving mail. Interviews conducted by LPA revealed the staff did not sign for any packages at the facility on 06/19/2021 and no staff checked the mail at the facility on 06/19/2021. The mail procedures at the facility have the administrator checking the mail Monday - Friday only. If a package comes on the weekend that would require a signature the administrator is notified, the staff on duty sign for the package and then staff leave it in the office for the administrator to process. There is no record to indicate the facility, the staff or R1 received a package on 06/19/2021. Postal records show the mail person left a package in the mail box at the facility address on 06/19/2021 at 2:20pm, this package was a certified letter with return receipt. The return receipt was not signed for by staff at the facility and the person that mailed the package to R1 did not receive a signed return receipt for the package sent. Interviews with Administrator's did not reveal any package left in the mail box over the weekend of 06/19-06/20, 2021. LPA did not observe the contents of the package in R1's room. R1 was served an envelope containing court documents on 05/25/2021 and those documents are present in R1's records. The facility does have a mail box at the front of the residence, it does not lock and it is accessible at the street. Staff log all residents property as it is received and LPA reviewed those log records. R1 did not have any property logged in during June 2021. The resides property logs are dated and kept in the residents files. Based on the lack of evidence the allegation is deemed Unsubstantiated at this time.

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

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2