<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405802555
Report Date: 02/26/2023
Date Signed: 02/26/2023 02:30:41 PM

Document Has Been Signed on 02/26/2023 02:30 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:
02/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Staff Back up to Administraor Nereida LealTIME COMPLETED:
02:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA De Leon conducted a Case management- deficiency visit to the facility above on 02/26/2023 at 1:15 pm. LPA met with Nereida Leal and explained the purpose of the visit.

LPA conducted an audit on 02/01/2023 of the facilities P&I funds for R1 during a complaint investigation # 29-AS-20230125120415 in which some deficiencies were found that did not pertain to the complaint allegation and are being addressed on this case management visit.

The facility provided LPA a copy of R1’s LIC 405 Record of Residents Safeguarded Cash Resources and a handwritten ledger of funds used for movie tickets. The receipts were not provided for these transactions of $3.95 for movie tickets. R1’s Resident Fund Management Service (RFMS) statement was reviewed and not all receipts for debits listed were provided. The statement and balances were accurate on these forms but not all receipts were provided. The staff interview revealed the facility does not keep any P&I funds at the facility and they are kept at the business office in San Luis Obispo, CA. The facility had to request the records from the business office to provide to LPA. The facility must provide the receipts to the business office which in turn provides them to the corporate office and if the Administrator or facility want a copy of any of the receipts, they must request a copy from the corporate office. The property purchased on R1’s RFMS statement between 07/26/2019-03/22/2022 was not all listed on the LIC 621 Resident Personal Property and Valuables Statement. Administrator did update the form and listed all property for R1 and provided a copy of the up-to-date LIC 621 to LPA by email later that day. The audit did not reveal any misuse of R1’s funds but it did reveal regulation deficiencies on record keeping of receipts and providing the LPA the requested records upon demand during normal business hours.

Exit interview conducted, deficiencies cited, copy of report and appeal rights printed and left with Staff. Emailed copy of report to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2023
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 02/26/2023 02:30 PM - It Cannot Be Edited


Created By: Rachael De Leon On 02/26/2023 at 01:32 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: 02/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2023
Section Cited
CCR
80026(h)(1)

1
2
3
4
5
6
7
(h)...(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to work with business office to provide the facility with all the receipts for the residents P & I Cash and Account funds debits/credit transactions.
8
9
10
11
12
13
14
Based on record review and audit of P&I funds the licensee did not comply with the regulation above supporting receipts were not provided for all transactions listed on the LIC 405, handwritten ledger, or the RFMS statement which poses a potential personal rights risk to residents in care.
8
9
10
11
12
13
14
 All staff that handled P&I funds must be trained, read, review, and abide by regulation 80026 provide a copy of staff signatures that participated to CCL.
Type B
03/06/2023
Section Cited
CCR80070(d)

1
2
3
4
5
6
7
(d) All client records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator with work with corporation so the facility can provide CCL with requested documents on demand during normal business hours.
8
9
10
11
12
13
14
Based on record review the licensee did not comply with the above regulation the facility was unable to provide all the records requested by the LPA on 02/01/2023 visit which poses a potential personal rights risk to residents in care.
8
9
10
11
12
13
14
 Train all staff, read, review, and abide by regulation 80070 and provide copy of staff signatures to CCL.
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: 02/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2