405850037-2-20-2025-29-AS-KBUY-DEATXA-20250227140649

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405850037
Report Date: 02/20/2025
Date Signed: 02/20/2025 02:59:55 PM

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
02/13/2025 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20250213124713

FACILITY NAME:	LA LOMA HOME		FACILITY NUMBER:	405850037
ADMINISTRATOR:	JUSTIN A PENROD		FACILITY TYPE:	735
ADDRESS:	1151 LA LOMA DR		TELEPHONE:	(805) 723-5104
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	4	CENSUS: 4	DATE:	02/20/2025
		UNANNOUNCED	TIME BEGAN:	12:26 PM
MET WITH:	Marisa Cardona		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff did not prevent residents from engaging in an altercation

INVESTIGATION FINDINGS:

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On 02/20/25 at 12:26 p.m. Licensing Program Analyst (LPA) Rankin conducted a 10-day complaint visit to the facility above. LPA met with Marisa Cardona, Program Director and explained the purpose of the visit.

During the investigation, LPA Rankin observed the facility, interviewed staff, interviewed resident, and reviewed and obtained relevant documents. At time of visit two (2) clients, and three (3) staff were on site. Facility is monitored by Tri-Counties Regional Center (TCRC).

On the allegation: Staff did not prevent residents from engaging in an altercation, the following incidents occurred and noted actions taken.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250213124713

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: 02/20/2025

NARRATIVE

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On 02/04/25 an incident report was received by Community Care Licensing (CCL) stating that on 1/31/25 two (2) clients were involved in an argument, Client #1 (C1) hit Client #2 (C2) in the face with a cane, and C2 hit C1 in the face with a lunch pail. Both staff on duty were within less than 10 feet from the residents. Staff placed themselves in-between the clients, addressed and ended the altercation. Following the altercation, per interviews, observation of the living room by LPA, and incident reports submitted, staff moved furniture to facilitate safe space between clients. Incident was reported on 2/3/25 to Program Director. Mandated Reporting training was conducted to reinforce time frames for reporting incidents.

On 2/1/25, C2 yelled that C3 hit them on their arm. C2 tried to scratch C3. Staff tried to encourage clients to separate and attempted to redirect clients. Clients refused. Clients C2 began yelling and C3 grabbed C2. Staff immediately responded and got between clients and directed C2 to go to their room. Staff #1 (S1) checked C2 for marks and found no marks on C2 at the time of the incident. LPA noted that C2 has a severe hunch or forward slump to their stance, and C2 is shorter in stature and during interview and previous interviews the view of the LPA for C2 was the top of their head. This is necessary to note, as S1 stated it wasn’t until they were on their way to the hospital with C2 that they noted a discoloring around C2’s eye. S1 does not believe the discoloring was there at the start of their shift on 2/1/25.

Following incidents C2 was taken to the Emergency Room due to agitation and pre-existing heart condition. Notes from hospital visit were obtained by LPA on 2/20/25. Notes indicate "ecchymosis" (discoloration) above the right eye. No other injuries found.

LPA interviewed C2 and asked about both incidents. C2 remembers being hit by a cane and confirmed that C3 grabbed C2. Interview with S1 confirmed events above with differing of they do not believe that contact was made with the first incident, but due to client and staff interviews done by management and LPA, it is believed that contact with the cane and lunch pail were made. Interview with S2, stated they were in the med area which has a direct line of site to the living room and S2 viewed the incident where C1 swung their cane and made contact with C2’s face.

LPA interviewed Deputy who responded to the incident, due to a call from the hospital. Deputy stated no crime was committed, no visible injuries were noted and interviews with caregiver stated that staff attempted to prevent and de-escalate the altercation.

continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250213124713

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: 02/20/2025

NARRATIVE

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In response to the additional altercation staff are trying to keep clients at a safe distance from each other and are staggering meal and med times and encouraging engagement in separate areas. Program Director added that contact was made with behavior specialists and Quality Inspectors with TCRC.

This facility was following standards pertaining to staffing at the time of the allegations, and during incident 2, there were an extra staff due to shift change. At the time of the physical altercation there was adequate supervision. Staff, and client confirmed their response was immediate, and that they worked to de-escalate with the appropriate methods. Based on interviews, observation, and documentation the allegation is deemed unsubstantiated.

Exit interview conducted, copy of report given.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC9099 (FAS) - (06/04)

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