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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802555
Report Date: 10/14/2022
Date Signed: 10/14/2022 05:18:30 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
05/13/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210513123904
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:
10/14/2022
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Ricardo Navarro, Back up to AdministratorTIME COMPLETED:
04:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was provided additional medication without notification to Responsible Party.
Facility staff did not communicate promptly with resident's responsible party.
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 the facility above. Administrator was not available. LPA met with Ricardo Navarro Back-up to Administrator and explained the purpose of the visit.

LPA’s Jeffries and Chaves conducted the initial 10-day complaint visit on 05/14/2021, collected records and interviewed staff. LPA De Leon conducted interviews with staff on 10/10/2022 at 11:47am, 10/11/2022 at 10:46am, 10/13/2022 at 10:18am and 11:28am and 10/14/2022 at 12:04pm. LPA interviewed witnesses on 04/11/2022 at 12:14pm, 10/13/2022 at 11:53am and 4:31pm.

On the allegation: Resident was provided additional medication without notification to Responsible Party. LPA conducted interview with W1 and S1 which revealed that R1
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 29-AS-20210513123904
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: 10/14/2022
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
26
27
28
29
30
31
32
was prescribed a new medication and staff failed to notify the POA of Health Care for R1. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation Facility staff did not communicate promptly with resident's responsible party. LPA conducted interviews with staff and witness which revealed a Power of Attorney for Healthcare naming 2 POA’s in order of preference and succession. Facility was notifying W2 but failed to notify W1 on several occasions regarding R1 and failed to notify W1 before informing W2. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to the Administrator.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210513123904
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: 10/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2022
Section Cited
CCR
87468.1(a)(8)
1
2
3
4
5
6
7
(a)...(8)To have their representatives regularly informed by the licensee of activities related to care...This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to train all staff in Personal Rights of Residents regulation 87468, 87468.1 and 87468.2, send up to date LIC 500 and all staff signatures for training to CCL.
8
9
10
11
12
13
14
Based on interviews and record review the licensee did not comply with the regulation above R1’s POA W1 was not notified prior to W2 and W1 was not notified of a new medication which possess a potential Personal Rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 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
LIC9099 (FAS) - (06/04)
Page: 6 of 6
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
05/13/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210513123904

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:
10/14/2022
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Ricardo Navarro, Back up to AdministratorTIME COMPLETED:
04:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not provide a copy of resident's records to responsible party.
Resident did not receive timely medical care.
Resident not accorded privacy while in care.
Facility failed to meet resident's needs.
Facility did not follow proper Covid-19 social distancing protocols
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 the facility above. Administrator was not available. LPA met with Ricardo Navarro Back-up to Administrator and explained the purpose of the visit.

LPA’s Jeffries and Chaves conducted the initial 10-day complaint visit on 05/14/2021, collected records and interviewed staff. LPA De Leon conducted interviews with staff on 10/10/2022 at 11:47am, 10/11/2022 at 10:46am, 10/13/2022 at 10:18am and 11:28am and 10/14/2022 at 12:04pm. LPA interviewed witnesses on 04/11/2022 at 12:14pm, 10/13/2022 at 11:53am and 4:31pm.

On the allegation: Facility did not provide a copy of resident's records to responsible party. LPA interviewed staff and witnesses which did not reveal any records requested
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20210513123904
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: 10/14/2022
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
26
27
28
29
30
31
32
that were not received. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Resident did not receive timely medical care. LPA interviewed W2 which revealed the facility did seek timely medical attention for R1 on several occasions. Interviews with staff revealed timely medical attention was sought for R1 on all occasions when R1 required medical care. Records reviewed did not reveal any mention of not seeking timely medical attention. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Resident not accorded privacy while in care. LPA interviewed staff and witness which revealed that all residents have a private room and staff give privacy to all residents in care. W1 stated that S1 did not provide privacy on a visit. S1 did approach R1’s room and introduced S1 self and asked if anyone had any questions that S1 was available. S1 left the doorway of R1’s room and returned to the living area where other staff and residents were present. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Facility failed to meet resident's needs. Based on staff and witness the facility has always been able to meet R1’s needs. R1 does have health issues and R1 has been hospitalized for medical reasons and medical attention was always given in a timely matter to R1. R1’s hospital discharges were done with R1 returning back to the facility or to skilled nursing then back to the facility when needed. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.
Continued 9099-C
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
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20210513123904
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: 10/14/2022
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
26
27
28
29
30
31
32
On the allegation: Facility did not follow proper Covid-19 social distancing protocols. LPA interviewed staff and witness which revealed staff, facility and visitors were following the proper Covid-19 Social distancing protocols at the facility. Records revealed sign-in, symptoms screening and temperature checking before any visitors were allowed in the facility. The facility did close visiting based on Governors orders and re-opened visitation when allowed and all requirements were met. The facility was not allowing in-person visitation during December of 2020-January of 2021 due to an outbreak at the facility and by public health officer orders. When the facility was able to open visitation all required procedures and protocols were being followed. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to the Administrator.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 6