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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802555
Report Date: 10/14/2022
Date Signed: 10/14/2022 05:21:28 PM

Document Has Been Signed on 10/14/2022 05:21 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:KERYE A. MARTINEZFACILITY TYPE:
740
ADDRESS:804 SOUTHLAND STTELEPHONE:
(805) 929-5096
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 4CENSUS: 4DATE:
10/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Ricardo Navarro, Back up to AdministratorTIME COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a case management visit to the facility above due to a complaint investigation #29-AS-20210513123904 revealing a deficiency that was not part of the complaint allegations. Administrator was not available. LPA met with Back up to Administrator Ricardo Navarro and explained the purpose of the visit.

According to the medical records of R1, R1 had two emergency room visits and a hospital admission in January 2021 that was not reported the Community Care Licensing (CCL) which is a requirement for facility reporting.

Exit interview conducted, deficiency cited, copy of report and appeal rights given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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 2
Document Has Been Signed on 10/14/2022 05:21 PM - It Cannot Be Edited


Created By: Rachael De Leon On 10/14/2022 at 04:25 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: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2022
Section Cited
CCR
87211(a)(1)(D)

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(a)...(1)... (D)Any incident which threatens the welfare, safety or health of any resident,...This requirement was not met as evidenced by:
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Licensee with train all staff on Regulation 87211 reporting requirements and send in an up to date LIC 500 and all staff signatures for training completed to CCL.
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Based on record review the licensee did not comply with the above regulation Staff did not report two ER visits to CCL which possess a potential Health and Safety 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: 10/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2022


LIC809 (FAS) - (06/04)
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