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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802555
Report Date: 07/14/2022
Date Signed: 07/14/2022 04:38:49 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
09/10/2020 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20200910110658
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: 4DATE:
07/14/2022
UNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Kathyrine Valdez, Back up to AdministratorTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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8
9
Staff are not adequately trained
INVESTIGATION FINDINGS:
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3
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5
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8
9
10
11
12
13
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings of the complaint allegations. LPA met with Administrator and explained the purpose of the visit.

LPA De Leon conducted the initial complaint visit on 09/17/2020 at 1:09 PM -1:52 PM and interviewed staff. LPA conducted interview with Witness on 09/18/2020. LPA conducted additional interviews with staff on 10/29/2020 and 11/12/2020. LPA requested the following documentation on 09/17/2020: Resident Roster, Resident ANS or IPP's, residents LIC 602A Medical Assessments, Resident Face Sheets with ID and Emergency Information, Copy of facility emergency plan LIC 610E, TCRC QA's and Service Coordinator's name and phone number, staff roster with telephone numbers, Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
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 5
Control Number 29-AS-20200910110658
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: 07/14/2022
NARRATIVE
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staff schedules for September 2020 and all Staff training records for initial or annual training Sept 2019-Sept 2020. LPA received documentation on 09/18/2020, 09/23/2020, 10/13/2020, 11/05/2020, 11/06/2020 and 11/09/2020. LPA reviewed all documentation on 07/12/2022 at 2:00 PM.

On the allegation: Staff are not adequately trained. LPA conducted interviews with staff, requested and reviewed documentation which revealed the staff did not have adequate dementia training to meet the needs of R1. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report emailed to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20200910110658
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2022
Section Cited
CCR
87707(a)(2)(A)(1-6)
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(a)...(2)...(A)...training topics shall be covered annually, and all topics shall be covered within a three-year period (1-6)...: This requirement was not met as evidenced by:
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Licensee/Administrator agree to review regulation 87707 and provide required dementia training on all topics that have not been covered in the past 3 years to all staff as required by regulation,
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Based on interviews and record review the licensee did not comply with the above regulation as staff did not have dementia training which poses an immediate health,Personal rights risk to residents in care
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proof of training and all staff signatures required to clear POC.
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
09/10/2020 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20200910110658

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: 4DATE:
07/14/2022
UNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Kathyrine Valdez, Back up to AdministratorTIME COMPLETED:
03:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not prevent inappropriate interactions between residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings of the complaint allegations. LPA met with Administrator and explained the purpose of the visit.

LPA De Leon conducted the initial complaint visit on 09/17/2020 at 1:09 pm -1:52 pm and interviewed staff. LPA conducted interview with Witness on 09/18/2020. LPA conducted additional interviews with staff on 10/29/2020 and 11/12/2020. LPA requested the following documentation on 09/17/2020: Resident Roster, Resident ANS or IPP's, residents LIC 602A Medical Assessments, Resident Face Sheets with ID and Emergency Information, Copy of facility emergency plan LIC 610E, TCRC QA's and Service Coordinator's name and phone number, staff roster with telephone numbers, staff schedules for September 2020 and all Staff training records for initial or annual training Sept 2019-Sept 2020
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20200910110658
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: 07/14/2022
NARRATIVE
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2
3
4
5
6
7
8
9
10
11
12
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15
16
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19
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21
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27
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LPA received documentation on 09/18/2020, 09/23/2020, 10/13/2020, 11/05/2020, 11/06/2020 and 11/09/2020. LPA reviewed all documentation on 07/12/2022 at 2:00 PM.

On the allegation: Staff does not prevent inappropriate interactions between residents. LPA interviewed staff which revealed staff do intervene with Resident 1 (R1) when R1 is having behaviors issues with other staff and residents. Staff interviews revealed R1’s diagnosis is worsening, R1 acts fast and staff have been unable to intervene in time when incidents have occurred, therefore this allegation is deemed Unsubstantiated at this time.

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

DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5