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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 04:23:32 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
10/21/2020 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20201021122125
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:Kahtyrine Valdez, Back up to AdministratorTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Improperly restraining resident in care
Behavior modification plans are not updated to reflect current needs of resident
Staff are not trained properly to meet the needs of the resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to deliver final findings of the complaint allegations. LPA met with Back up to Administrator Kathyrine Valdez and explained the purpose of the visit.

LPA De Leon conducted the initial complaint visit on 10/29/2020 and interviewed staff. LPA conducted additional interviews with staff on 11/12/2020, 12/22/2020, and 12/24/2020. LPA requested the following documentation on 10/29/2020: Resident Roster, Amended IPP for R1, any training's given to staff, staff roster with telephone numbers, staff schedules for October 2020. LPA received documentation on 11/05/2020, 11/06/2020 and 11/09/2020. LPA reviewed all documentation on 07/12/2022 at 2:00 PM.
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-20201021122125
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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On the allegation: Improperly restraining resident in care. LPA conducted staff interviews which revealed some staff tie R1’s wheelchair wheels so he can’t move around the facility. LPA reviewed R1’s file and R1 does not have current doctor’s orders for the postural supports being used with R1. The facility does not have any approved exceptions on file with the department for R1 and/or the postural supports being used: Wheelchair with Seat Belt, Seat Belt with PIN, and Gait Chair which are limiting R1’s abilities in using R1's hands and feet, as well as R1 is unable to quick release from the postural support being used. Based on the evidence this allegation is Substantiated at this time.

On the allegation: Behavior modification plans are not updated to reflect current needs of resident. LPA interviewed staff and requested documentation. Interviews with staff revealed the facility resident and staff files were not current and up to date at the facility. LPA requested documentation on 10/29/2020 which was not provided by the facility until 6-10 days later. The documentation received on 11/05/2020-11/09/2020 was up to date at the time is was sent to the department. The facility is required to have records readily available to the LPA for inspection when requested. Based on the evidence this allegation is Substantiated at this time. The deficiency and plan of correction for this allegation is being addressed and issued on complaint number 29-AS-20200916132639.

On the allegation: Staff are not trained properly to meet the needs of the resident. LPA conducted interviews with staff that revealed they have not had any dementia training, they do have online training provided but no in-person or hands-on training is being completed. LPA requested and reviewed training documentation which reveals the facility staff do not have any current dementia training. Based on the evidence this allegation is deemed Substantiated at this time. The deficiency and plan of correction for this allegation is being addressed and issued on complaint number 29-AS-20200910110658.

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: 2 of 3
Control Number 29-AS-20201021122125
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
87608(a)(3)
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(a)...(3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record...This requirement was not met as evidenced by:
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Licensee/Administrator agreed to review all residents’ records and update any records for current LIC 602’s, Doctor’s orders and complete an exception request for each resident to the department if
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Based on interviews and record review the licensee did not comply with the regulation above R1 did not have any doctors orders for the postural supports and the postural supports were being used by staff to limit R1’s abilities which poses an immediate health, safety and personal rights risk to residents in care.
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needed. Review and train all staff on regulation 87608. Send proof of record review, training and all 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)
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