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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850052
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:17:28 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
12/29/2021 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20211229153609
FACILITY NAME:PARK PLACE ASSISTED LIVINGFACILITY NUMBER:
405850052
ADMINISTRATOR:BARNHILL, DIANAFACILITY TYPE:
740
ADDRESS:7500 PORTOLA RDTELEPHONE:
(805) 591-9855
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:13CENSUS: 12DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Diana Barnhill, Licensee/AdministratorTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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COVID-19 screening protocols are not being followed
Covid-19 masking protocols are not being followed
INVESTIGATION FINDINGS:
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On 9/21/2022 at 1:18 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced follow-up complaint visit to the facility above. LPA met with Diana Barnhill, Licensee/Administrator, and explained the purpose of the visit.

On the allegations, “COVID-19 screening protocols are not being followed,” and “Covid-19 masking protocols are not being followed,” the complainant’s concern was that visitors were not screened for COVID-19 upon entry to the facility and two caregiving staff were observed not properly wearing masks. To investigate the allegations, LPA made observations and took photos.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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-20211229153609
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: PARK PLACE ASSISTED LIVING
FACILITY NUMBER: 405850052
VISIT DATE: 09/21/2022
NARRATIVE
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On 12/21/21 at 2:15 pm, credible Witnesses #1 (W1) and #2 (W2) say they were not screened for COVID-19 upon entry to the facility. They state staff did not perform temperature checks or any other screening method upon entry to the facility. During the visit, they observed two caregivers wearing masks that did not cover their noses. One caregiver's mask did not cover their mouth while they were giving care to residents.

On 1/3/22 at 2:02 pm, LPA visited the facility and upon entry was not screened for COVID-19. LPA requested that staff conduct screening upon which staff then took LPA’s temperature and asked LPA to sign the visitor log. LPA took photos of the visitor log and observed that staff and visitors are signing in, however, LPA and credible witnesses were not screened during their visits on 12/21/21 and 1/3/22.

Based on the evidence obtained, the allegations “COVID-19 screening protocols are not being followed,” and “Covid-19 masking protocols are not being followed,” are deemed Substantiated at this time. The facility did not protect the personal rights of residents in care to be able to receive safe and healthful accommodations in that the facility staff failed to wear face coverings properly while providing care and supervision to residents in care and did not screen visitors for COVID-19. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on 9099-D.

Exit interview conducted, deficiency cited, and the report and appeal rights emailed to Licensee.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20211229153609
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: PARK PLACE ASSISTED LIVING
FACILITY NUMBER: 405850052
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2022
Section Cited
CCR
87468.1
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87468.1 Personal Rights. Residents have the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Infectious control training will be held with staff, and licensee will emphasize the reasons for proper use of PPE for residents and staff which will be completed by 9/28/22. Licensee will send a staff sign-in sheet from the training with staff printed names, signatures, and date of training immediately upon training being completed. Licensee will send LPA a commitment by 9/22/22 to complete the training by 9/28/22.
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Based on observations and witness testimony, the facility failed to ensure staff were wearing face coverings and did not screen visitors which poses an immediate health, safety and personal rights 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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
12/29/2021 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20211229153609

FACILITY NAME:PARK PLACE ASSISTED LIVINGFACILITY NUMBER:
405850052
ADMINISTRATOR:BARNHILL, DIANAFACILITY TYPE:
740
ADDRESS:7500 PORTOLA RDTELEPHONE:
(805) 591-9855
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:13CENSUS: 12DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
01:18 PM
MET WITH:Diana Barnhill, Licensee/AdministratorTIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Food safety protocols are not being followed
Sufficient quantity and/or quality of food not available for the residents in care
INVESTIGATION FINDINGS:
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On 9/21/2022 at 1:18 pm, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced follow-up complaint visit to the facility above. LPA met with Diana Barnhill, Licensee/Administrator, and explained the purpose of the visit.

On the allegation, “Food safety protocols are not being followed,” the complainant’s concern was that a package of ground beef was sitting on the counter. To investigate, LPA interviewed staff and made observations.

On 1/3/22 at 2:07 pm, LPA observed no perishable, open food on the counter except mandarin oranges.

Continued on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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-20211229153609
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: PARK PLACE ASSISTED LIVING
FACILITY NUMBER: 405850052
VISIT DATE: 09/21/2022
NARRATIVE
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On 9/21/22 between 1:28 pm and 2:07 pm, LPA interviewed Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3). All three staff say that food is not left on the counter and specifically mentioned that they do not do this due to the fact residents sometimes enter the kitchen and take food. Staff describe the process of thawing food as moving frozen food from the freezer to the refrigerator and placing it in a tray. Staff say when they’re ready to use it, they remove the thawed food from the refrigerator. At 2:14 pm, LPA observed a tray of pork chops in the refrigerator. At 2:26 pm, LPA observed S3 preparing dinner. S3 took the pork chops from the refrigerator, prepared them in a separate dish, and immediately placed them in the oven.

Based on the evidence obtained, the allegation, “Food safety protocols are not being followed,” is deemed Unsubstantiated at this time. LPA observations and staff interviews indicate food is being stored properly.

On the allegation, “Sufficient quantity and/or quality of food not available for the residents in care,” the complainant was concerned that there was no fresh fruit in the facility. To investigate the allegation, LPA made observations, took photos, and reviewed records.

On 1/03/22 at 2:07 pm, LPA toured the kitchen and observed the following: There was a basket of nine mandarin oranges on the counter, twelve cans of fruit and one banana in the pantry, ten to twelve pears in the refrigerator, a gallon container of orange juice, a 48 ounce jar of prune juice, and a 47 ounce jar of applesauce.

On 9/21/22 at 2:15 pm, LPA observed a basket of apples and pears on the counter and in the kitchen open cabinet, two bunches of bananas, a bag of mandarin oranges, a watermelon and cantaloupe.

Based on the evidence obtained, the allegation “Sufficient quantity and/or quality of food not available for the residents in care,” is deemed Unsubstantiated at this time. LPA observed a sufficient quantity and quality of produce available in the facility.

Exit interview conducted and the report emailed to the licensee.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5