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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802555
Report Date: 04/08/2022
Date Signed: 04/08/2022 01:45:57 PM

Document Has Been Signed on 04/08/2022 01:45 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SOUTHLAND HOMEFACILITY NUMBER:
405802555
ADMINISTRATOR:KATHYRINE VALDEZFACILITY TYPE:
740
ADDRESS:804 SOUTHLAND STTELEPHONE:
(805) 929-5096
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 4CENSUS: 4DATE:
04/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Administrator Kathyrine ValdezTIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) De Leon conducted a Case Management (CM)- Deficiencies visit to the facility above. LPA met with Administrator Kathyrine Valdez and explained the purpose of the visit.

Community Care Licensing (CCL) received complaint # 29-AS-20220202105403 on 02/02/2022 and during the complaint investigation deficiencies were observed these deficiencies did not relate to the complaint allegations and therefore are being addressed on this CM visit.

CCL Investigation Branch conducted the investigation. During the physical plant tour on 02/14/2022 Investigator Munoz observed the following deficiencies: During the physical plant tour the investigator took photos of the resident 1 (R1's) bedroom. Photographs show a baby monitor in the resident’s room. Staff interviews also confirmed they use baby monitors for the residents. LPA De Leon spoke with Staff at the facility and explained that baby monitors are a personal rights violation and if the facility wanted a device for residents to get help, they must comply with the regulation requirements. Staff removed baby monitors from the resident’s room and will work with corporation to provide something to residents that met the regulation requirements. During the investigation facility records were reviewed and the following were noted by the Investigator: Resident #1 (R1) has SIB and uses bi-lateral arm splints with a Dr. order dated 10/11/2018. LPA De Leon reviewed the facility record and CCL does not have an approved exception for R1 on file for the use of these on R1. The documentation reviewed for R1 shows a physician report LIC 602A dated 11/30/2021 stating R1 is total care . LPA De Leon reviewed the facility record and CCL does not have an approved exception on file for the total care of R1.

Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to the Administrator/Licensee.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 04/08/2022 01:45 PM - It Cannot Be Edited


Created By: Rachael De Leon On 04/08/2022 at 01:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SOUTHLAND HOME
FACILITY NUMBER: 405802555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2022
Section Cited
CCR
87468.2.(a)(1)

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87468.2 (a)(1)...personal privacy in accommodations,... and assistance, visits, communications, telephone conversations,... This requirement was not met as evidenced by:
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Administrator agreed to read and review regulation 87468.2, train staff and sign documentation, baby monitors have been removed from facility. If the facility is going
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Based on observation the license did not comply with the above as R1 had baby monitors in their bedroom which poses a potential personal rights risk to residents in care.
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to provide any type of device for the resident it will met regulation requirements. Send documentation to CCL by 04/12/22
Type B
04/11/2022
Section Cited
CCR87608(a)(2)

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(a)...resident is unable to do for himself/herself...may be used under the following...(2)...shall...in a manner that permits quick release by the resident. This requirement was met as evidenced by:
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Administrator agreed to immediately send documentation to CCL for an exception request for R1’s bi-lateral arm splints.
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Based on documentation the licensee did not comply with the above as R1 is not able to release/takeoff the postural supports and an exception has not been approved by CCL which poses a potential safety and personal rights risk to the resident 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 Burley
LICENSING EVALUATOR NAME:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/08/2022 01:45 PM - It Cannot Be Edited


Created By: Rachael De Leon On 04/08/2022 at 01:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SOUTHLAND HOME
FACILITY NUMBER: 405802555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2022
Section Cited
CCR
87615(a)(5)

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(a)...(5)Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement was not met as evidenced by:
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Administrator agreed to immediately send documentation to CCL for an exception request for R1’s total care.
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Based on documentation the license did not comply with the above as R1 had a physician report dated 11/30/2021 stating R1 was total care and no exception approval on file for R1 with CCL which poses a potential 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 Burley
LICENSING EVALUATOR NAME:Rachael De Leon
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2022


LIC809 (FAS) - (06/04)
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