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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802555
Report Date: 07/01/2024
Date Signed: 07/02/2024 07:58:48 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
06/24/2024 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20240624153403
FACILITY NAME:SOUTHLAND HOMEFACILITY NUMBER:
405802555
ADMINISTRATOR:KERYE A. MARTINEZFACILITY TYPE:
740
ADDRESS:804 SOUTHLAND STTELEPHONE:
(805) 929-5096
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:4CENSUS: 4DATE:
07/01/2024
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Nereida Leal, Back-up AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff are not properly storing residents' medications.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted a 10-day complaint visit to the facility above. LPA met with back up Administrator and explained the purpose of the visit.

On the allegation staff are not properly storing residents' medications. LPA toured kitchen area where medication is stored. At time of visit medication cabinet and lock box inside refrigerator were found secured and locked in compliance with regulations. Other areas were inspected for required securing of items, all areas were found in compliance at time of visit. Review of staff files for training found that the appropriate training was done during orientation regarding safeguarding medication and handling of medication.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
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 2
Control Number 29-AS-20240624153403
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SOUTHLAND HOME
FACILITY NUMBER: 405802555
VISIT DATE: 07/01/2024
NARRATIVE
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LPA suggested a review of medication and the importance of consistently securing them be done during this years annual training for a reminder of this regulation and its importance.

Based on the records obtained and observation on the day of LPA’s visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted, copy of report printed and provided to Back-up Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2