405802555-2-26-2023-29-AS-KBUY-CPFU6K-20230227141828

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405802555
Report Date: 02/26/2023
Date Signed: 02/26/2023 02:29:00 PM

Unsubstantiated

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
01/25/2023 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20230125120415

FACILITY NAME:	SOUTHLAND HOME		FACILITY NUMBER:	405802555
ADMINISTRATOR:	KERYE A. MARTINEZ		FACILITY TYPE:	740
ADDRESS:	804 SOUTHLAND ST		TELEPHONE:	(805) 929-5096
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	4	CENSUS: 4	DATE:	02/26/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Staff Back up to Administrator Nereida Leal		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Facility is misusing resident's funds.

INVESTIGATION FINDINGS:

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Licensing Program Analyst De Leon conducted a subsequent Complaint visit to deliver final findings to the facility above. LPA arrived at 1:15 PM to the facility. LPA met with Nereida Leal, Staff back up to Administrator at 2:10 pm and explained the purpose of the visit.

LPA De Leon conducted the initial complaint visit on 02/01/2023 at 10:00 am, conducted interview at 10:15 am and requested records for Resident 1 and reviewed some of R1’s records. LPA interviewed Witnesses on 01/25/2023, on 01/31/2023 at 11:33 am, on 02/06/2023, on 02/13/2023. LPA De Leon reviewed R1’s additional records on 02/24/2023 and 02/25/2023. Continued 9099-C

Unsubstantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230125120415

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: 02/26/2023

NARRATIVE

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On the allegation: Facility is misusing resident's funds. LPA conducted interviews with staff and witnesses that revealed the debit transactions and reimbursements for the transactions listed in this complaint did not go through the facilities P&I Funds for Resident 1 (R1), R1’s funds used in these transactions did not have any type of involvement with the Licensee or staff at this facility. LPA conducted an audit of the facility P & I funds for R1 and there is no evidence of the misuse of R1’s funds or evidence that any of the debit transactions listed in this complaint were R1’s P&I funds. The debit transactions in question were funds through Tri-Counties Regional Center (TCRC) Trust Management Services (TMS) and not P&I funds through the facility. Based on the evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report 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

LIC9099 (FAS) - (06/04)

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