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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802555
Report Date: 10/01/2024
Date Signed: 10/01/2024 12:09:37 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
09/27/2024 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20240927102202
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:
10/01/2024
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Nereida Leal - House Manager and
Ricardo Navarro - Administrator		TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not following food safety protocols for residents in care.
INVESTIGATION FINDINGS:
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At 10:08 am on 10/1/24, Licensing Program Analyst (LPA) M. Rankin conducted a required 10 Day Complaint visit. LPA met with House Manager (HM) Nereida Leal who accompanied LPA on the inspection. At 10:40 am LPA met with Administrator Ricardo Navarro to review report. At time of visit, 1 HM, 1 caregiver and the administrator were at the facility, and there were 2 residents present.

On the allegation: Staff are not following food safety protocols for residents in care the following was determined.

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

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
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 4
Control Number 29-AS-20240927102202
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: 10/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2024
Section Cited
CCR
87555(a)
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87555 General Food Service Requirements (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 is not met as evidenced by:
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Licensee agrees to provide training. Facility will provide document with staff signatures of those who attended.
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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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 Additionally, Administrator agrees to conduct weekly food check to ensure food management is being upheld. Documentation will be submitted to LPA via email no later than 10/18/2024.
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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: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20240927102202
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: 10/01/2024
NARRATIVE
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At 10:13 am LPA conducted a tour of the kitchen area and inspected all food in the refrigerator and freezer and found that at time of visit all items were properly labeled, no expired food was found in the refrigerator and all vegetables were fresh with no evidence of decay. LPA at 10:20 am reviewed pantry area and found a package of chocolate chips with an expiration date of 8/16/24, a package of Pumpkin Spice Pancake mix with expiration date of 7/12/24, and a package of Croutons, with expiration date of 10/6/23. At 10:27 am LPA reviewed cabinet with canned and jarred goods and found 2 jars of Country Gravy with expiration date of 9/15/24. (Pictures taken of all items.)

At 10:41 am LPA discussed the allegations with the Administrator. The complainant stated on 9/24/24 a visit was done by the local ombudsman. Complainant stated the following: “observed several food items in the refrigerator that were not properly wrapped or labeled, including bacon and salami, pizza slices dated 9-12-24, cut lettuce that was turning brown, and a bag of green squash with at least one that was very soft." Picture evidence of expired food was provided to CCLD.

At this time based on the evidence provided by the complainant, training records provided by facility of expectations, interviews conducted with HM and administrator, and the items found at time of visit by the LPA, the complaint is Substantiated.

During preparation for visit LPA viewed facilities history and noted a prior deficiency on 7/1/24 for same Title 22 regulation 87555(a). LPA determined this is a repeat violation and an Immediate Civil Penalty of $250 was assessed for the Repeat Violation.
During inspection LPA stated to HM that the training document provided to LPA for prior deficiency had specific requirements regarding how often staff will be inspecting food. The document emailed to LPA on 7/8/24 was, Training In-Service Record document, with title Agenda “Food Safety” dated 7/3/24 which was given to clear prior deficiency, noted the training included: “1. All food stored in refrigerator will be checked for expiration by NOC staff every other day. 2. Food stored in refrigerator will be thrown out after 2 days of being prepared regardless of being staff or house food. 3. NOC staff will check dry goods for expiration every Wednesday and throw away any expired food.” Six (6) staff noted receiving this training.
Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20240927102202
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: 10/01/2024
NARRATIVE
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House manager and Administrator both stated they will be “purchasing a small staff refrigerator to separate items that belong to staff”. HM stated, “part of the food found are staffs”. Administrator stated they will conduct training with all facility staff, additionally administrator will do weekly checks of food to ensure staff are following training and regulations. Administrator will provide in-service training document signed by all staff as Plan of correction to LPA.

An exit interview was conducted, Citation and Civil Penalty Fee given, and Appeal Rights were discussed with Licensee. Report was provided to Licensee. Please see 809D for citation and LIC 421FC for Civil Penalty Assessment.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4