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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802555
Report Date: 07/01/2024
Date Signed: 07/01/2024 03:58:34 PM

Substantiated


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:
04:15 PM
ALLEGATION(S):
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Staff are not following food safety protocols for residents in care.
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 following food safety protocols for residents in care. LPA toured kitchen area, interviewed a residence and the back-up administrator. At the time of visit LPA went through the refrigerator to inspect all food items. LPA found a spoiled cucumber, expired mixed salad greens, as well as expired yogurt. Pictures were taken of expired items. A storage container was also found, dated 6/19/24 with rice inside. LPA observed a sign on the refrigerator directing staff to

Continued on 9099-C
Substantiated
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 3
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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 “Please throw away any made food within the 2 days it was made” as well as “Please make sure that all food is to be labeled with the date it was made....opened..." LPA also inspected a large sampling of dry goods and found 3 items expired from within the past month to 6 months.

LPA requested the following documents: 3 staff files for review of training, and a copy of the menu. Training documents showed training was done during orientation regarding preparation and resident support for special diets.

Based on interviews conducted and observations made, the allegation that facility staff are not following food safety protocols for residents in care is Substantiated at this time.

The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were issued at the time of the visit.
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: 3 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/08/2024
Section Cited
CCR
87555
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Type B 87555 (a) The total daily diet shall be of the quality... necessary to meet the needs of the residents... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement
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Licensee agrees to provide a written statement to CCLD acknowledging regulation 87555 and how the facility will regulate food compliance going forward. Plan will be submitted to LPA via email no later than 7/8/2024.
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is not met as evidenced by: Based on interviews, and observation, the licensee did not comply in the section cited above as spoiled/expired food was found which poses a health and safety risk to residents in care.
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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: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

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

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