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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850037
Report Date: 08/23/2024
Date Signed: 08/23/2024 04:33:29 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
07/17/2024 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20240717125653
FACILITY NAME:LA LOMA HOMEFACILITY NUMBER:
405850037
ADMINISTRATOR:JUSTIN A PENRODFACILITY TYPE:
735
ADDRESS:1151 LA LOMA DRTELEPHONE:
(805) 723-5104
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:4CENSUS: DATE:
08/23/2024
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Marisa CardonaTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not treat resident with respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melisa Rankin along with Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Miquel Magana conducted a subsequent complaint visit to the facility above to issue final findings. LPA met with Program Director (PD), Marisa Cardona and explained the purpose of the visit.

During the investigation, LPA Rankin and QAS Magana conducted the initial Case Management visit on 7/17/24 from 9:00 am to 11:00 am and LPA Rankin returned for the 10-day required complaint visit 7/23/24 from 3:26 pm to 4:00 pm. During the initial Case Management visit an interview was done with the PD, and LPA obtained relevant documentation.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
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-20240717125653
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: LA LOMA HOME
FACILITY NUMBER: 405850037
VISIT DATE: 08/23/2024
NARRATIVE
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LPA and QAS conducted interviews with 6 staff on 8/8/24 throughout the day starting at 9:13 am to 5:00 pm and 1 staff on 8/9/24 from 4:00 pm to 4:32 pm and 1 final staff interview on 8/23/24.

On the allegations: Staff 2 (S2) was in the laundry room area with Resident 1 (R1). R1 was arguing with S2 and refusing to complete their laundry task. S2 stated Staff 1 (S1) entered the laundry area, grabbed R1 by both arms, and using force made R1 move stating “no you’re going to do it now.”

After interviews with 8 staff, the preponderance of evidence shows that, besides S2 stating the event occurred, other staff state they did not witness the event or any other events like it from the behavior of S1. Staff all noted that they have not seen or heard of aggressive behavior of any kind from S1. R1 did not mention the event where anyone grabbed or yelled at them. Internal investigation by the Quality Control Unit deemed the allegation as unsubstantiated, no evidence that this event occurred.

Based on interviews conducted with 8 staff, including the AD, and R1, this allegation is deemed Unfounded as there is no reasonable basis suggesting that the event occurred.

On the allegation: S1 took a plate from R1 the allegation was that on 3 separate witnessed incidents, S1 took a plate from R1, when S2 was asked why they thought S1 took the plate it was documented that they said “the first time R1 was falling asleep, but there was still food on the plate and S1 yelled ‘go to your room’”. The other times the plate was taken the documented reason from S2 was because S1 said R1 was “sucking her fingers.”

Interview conducted on 8/9/24 at 4:00 pm S1 stated they do not take food from clients, but S1 noted on one occasion R1’s plate was removed, per S1 it was empty, and R1 proceeded to throw a fork and spook at S1. LPA and QAS interviewed R1 who stated there are some staff who have taken R1's plate, but did go into further detail regarding any incidents. During interviews with staff, other staff mentioned incidents where staff have removed a plate from R1. Internal investigation by the Quality Control Unit further deemed the allegation as Substantiated regarding the taking a plate incident. The investigation revealed that removing R1’s plate was common for all staff because R1 was either done, had fallen asleep, or R1 was taking an extremely long time.

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

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20240717125653
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: LA LOMA HOME
FACILITY NUMBER: 405850037
VISIT DATE: 08/23/2024
NARRATIVE
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Based on interviews and information obtained, the allegation that staff did not treat resident with respect is deemed Substantiated. This is against R1’s personal right to be afforded time needed to finish R1’s meal as they require and for as long as they require.

Documentation collected 8/23/24 was recent training for staff on resident rights, and mandated reporting.

Exit interview conducted, deficiency cited on 9099-D, copy of report given, appeal rights given.

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

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 29-AS-20240717125653
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: LA LOMA HOME
FACILITY NUMBER: 405850037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2024
Section Cited
CCR
80072(a)(3)
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(a)“.. each client shall have personal rights ”…(3)To be free from…. humiliation, intimidation, ridicule, coercion,.., or other actions of a punitive nature, including, but not limited to: interference with the
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Program Director agreed to provide training on Mandated Reporting, Resident Rights, and updating R1 behavior plan to address the food incidents.
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daily living functions, including eating….”
Based on interviews and documentation the licensee did not comply with the section cited above when the facility did not
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recognize and address staff removing plates from a resident.
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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: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4