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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850037
Report Date: 08/18/2022
Date Signed: 08/18/2022 01:17:13 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
07/02/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210702140328
FACILITY NAME:LA LOMA HOMEFACILITY NUMBER:
405850037
ADMINISTRATOR:WESLEY J. MARKINGFACILITY TYPE:
735
ADDRESS:1151 LA LOMA DRTELEPHONE:
(805) 723-5104
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:4CENSUS: 4DATE:
08/18/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Justin Penrod, Back up to AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff confiscated resident's medical device.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to issue final findings of the allegations. LPA met with Justin Penrod and explained the purpose of the visit.

LPA De Leon received phone call on 06/25/2021 from Administrator self-reporting the incident. On 06/27/2021 facility Administrator submitted a written incident report and SOC 341 to all required agencies. APS submitted SOC 341 cross-report to Community Care Licensing (CCL), On duty LPA generated a complaint not realizing it was a self-reported incident from the facility. LPA De Leon conducted the initial 10-day complaint visit on 07/08/2021, interviewed staff and resident around 2:30pm. LPA requested and reviewed documentation on 07/08/2021. LPA De Leon interviewed additional staff on 07/28/2021 at 10:52am and 11:00am. Continued 809-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
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 5
Control Number 29-AS-20210702140328
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: LA LOMA HOME
FACILITY NUMBER: 405850037
VISIT DATE: 08/18/2022
NARRATIVE
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 Facility investigated the incident and S2 received a write up and was required to retake personal rights training. S2 did not sign the paperwork and found other employment and did not return to work with the corporation or facility.

On the allegation: Staff confiscated resident's medical device. LPA conducted interviews with staff and residents which revealed S2 did remove R1 from the kitchen area and then proceed to remove R1’s cane from R1. Interview with resident revealed R1 was not doing anything wrong and was in the kitchen helping S3. Staff interview with S3 revealed R1 was in the kitchen and was not doing anything to be removed from the kitchen area. S3 also observed S2 remove R1’s cane and place it on the medication table. S2 stated S2 was not aware that S2 was violating R1’s personal rights and felt R1 did not belong in the kitchen area. S2 also stated S2 removed R1’s cane because R1 was upset for being removed from the kitchen area and when R1 gets upset R1 can act out inappropriately so S2 made the decision to take R1’s cane and place it on the medication table letting R1 know that when R1 calmed down S2 would give R1’s cane back. Shortly after the incident S2 returned R1’s cane to R1. Based on the evidence this allegation is Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20210702140328
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: LA LOMA HOME
FACILITY NUMBER: 405850037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/22/2022
Section Cited
CCR
80065(l)
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(l) Personnel shall provide for the care and safety of persons without physical or verbal abuse, exploitation or prejudice. This requirement was not met as evidenced by:
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Administrator agreed to re-train all staff in Personnel 80065, personal rights regulations 80072 & 85072, provide proof of training and all staff signatures to CCL. Administrator to make sure personal rights regulations
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Based on interviews the licensee did not comply with the regulation above, S2 removed R1 out of the kitchen and took R1’s cane away which posses an immediate personal rights risk to residents in care.
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are posted in the common area of the facility.
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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: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
07/02/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210702140328

FACILITY NAME:LA LOMA HOMEFACILITY NUMBER:
405850037
ADMINISTRATOR:WESLEY J. MARKINGFACILITY TYPE:
735
ADDRESS:1151 LA LOMA DRTELEPHONE:
(805) 723-5104
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:4CENSUS: 4DATE:
08/18/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Justin Penrod, Back up to AdministratorTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident hitting another resident in care.
Staff handled resident in a rough manner.
Staff spoke in an aggressive manner towards resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above to issue final findings of the allegations. LPA met with Back up to Administrator Justin Penrod and explained the purpose of the visit.

LPA De Leon received phone call on 06/25/2021 from Administrator self-reporting the incident. On 06/27/2021 facility Administrator submitted a written incident report and SOC 341 to all required agencies. Adult Protective Services (APS) forwarded the same SOC 341 cross-report to Community Care Licensing (CCL). LPA De Leon conducted the initial 10-day complaint visit on 07/08/2021, interviewed staff and resident around 2:30pm. LPA requested and reviewed documentation on 07/08/2021. LPA De Leon interviewed additional staff on 07/28/2021 at 10:52am and 11:00am.
Continued 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20210702140328
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: LA LOMA HOME
FACILITY NUMBER: 405850037
VISIT DATE: 08/18/2022
NARRATIVE
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 Facility investigated the incident and S2 received a write up and was required retake Residents personal rights training. S2 did not sign the paperwork and found other employment and did not return to work with the corporation or facility.

On the allegation: Staff did not provide adequate supervision resulting in resident hitting another resident in care. The facility reported that Resident 2 (R2) told staff that another resident 1 (R1) had hit R2 earlier in the day on 06/25/2021. The facility did not file an incident report to CCL as they had no evidence that anything had occurred that day. R2 had no injuries. Facility conducted an internal investigation and none of the staff had witnessed any altercations with R1 and R2 on that day. R1’s interview revealed no incident occurring with R2 and R1 stated R1 did not hit anyone. R2 did not want to talk with LPA. The facility always has two staff on duty and on that day all staff worked their shifts. Tri-Counties Regional Center Quality Assurance staff stated the facility is staffing accordingly to the allotted hours of staff per shift. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Staff handled resident in a rough manner. LPA conducted interviews with staff and resident which did not reveal any staff handled R1 in a rough manner. R1 did not feel S2 handled R1 in a rough matter. S2 stated S2 did not handle R1 in a rough manner. S3 stated S3 observed the incident stating that S2 wheeled R1 out of the kitchen area because S2 did not think it was a safe place for R1 to be, S3 then observed R1 upset and S2 removing R1’s cane and placing it on the medication table. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

On the allegation: Staff spoke in an aggressive manner towards resident. LPA conducted interviews with staff and resident which revealed S2 did not speak aggressively to R1. R1 stated S2 did not speak to R1 in an aggressive manner only that S2 wheeled R1 in R1’s wheelchair out of the kitchen area when R1 wanted to stay in the area then S2 took R1’s cane away. Based on the lack of evidence this allegation is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5