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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 04:32:36 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
09/16/2020 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20200916132639
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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Resident's files are inaccurate.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to deliver final findings on the complaint allegation. LPA met with Back up Administrator Kathyrine Valdez 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 interviewed additional 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.
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 3
Control Number 29-AS-20200916132639
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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 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: Resident's files are inaccurate. LPA conducted interviews with staff and witness which revealed R2 was sent to the hospital in 08/2020 without an up to date emergency face sheet that R2 was on a pureed diet. LPA observed the face sheet that was sent with resident at that time which did not reflect that R2 was on a pureed diet. LPA reviewed R2’s Hospital Discharge packet which revealed discharge diet was a regular diet and did not mention pureed diet. LPA conducted interviews that revealed the resident and staff forms were not up to date at the facility and after the 09/17/2020 complaint visit the facility staff began updating all the facility files on residents and staff. LPA requested documentation on 09/17/2020 from the facility and on 09/18/2020 LPA was sent Emergency Face Sheets for each resident in care that seemed to be up to date. The updated document for R2 did reflect R2’s pureed diet. The facility was unable to send all the requested documentation LPA requested due to the facility files not being up to date and accurate, therefore the allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights 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: 3 of 3
Control Number 29-AS-20200916132639
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
87506(a)
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(a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility...readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by:
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Licensee/Administrator agree to review all resident files and make sure they have all required forms/documents, review regulation 87506 and have all staff trained, provide proof of training and all
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Based on observation and record review the licensee did not comply with the above regulation. Resident files were not complete and current which poses a immediate health and safety risk to residents in care.
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staff signatures to CCL.
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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 3