421700411-7-9-2021-29-AS-KBUY-CCEV3K-20220311150452

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 421700411
Report Date: 07/09/2021
Date Signed: 07/09/2021 03:18:25 PM

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
06/29/2021 and conducted by Evaluator Toan Luong

COMPLAINT CONTROL NUMBER: 29-AS-20210629102735

FACILITY NAME:	VALLE VERDE		FACILITY NUMBER:	421700411
ADMINISTRATOR:	SUSAN E PONCE		FACILITY TYPE:	741
ADDRESS:	900 CALLE DE LOS AMIGOS		TELEPHONE:	(805) 883-4000
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93105
CAPACITY:	547	CENSUS: 364	DATE:	07/09/2021
		UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Susan Ponce, Administrator		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Facility failed to safeguard resident's belongings
Facility did not report missing items.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Toan Luong made an unannounced initial 10-Day complaint visit. LPA arrived at the facility at 9:01 am and announced the purpose of the visit.
During the visit, LPA conducted a Safety and Welfare tour of the facility.
From 9:55 AM – 12:45 PM, LPA Luong conducted in-person interviews and obtained copies of documents pertaining to the investigation. LPA Kristin Kontilis conducted telephone interviews and participated in the investigation.
On 6/20/2021, Resident 1’s (R1’s) eyeglasses and wristwatch went missing after R1 sustained a fall in the Independent Living area of the facility. 9-1-1 was called, R1 was transported to the hospital and subsequently admitted into the skilled nursing unit of the facility. Documents reviewed revealed that R1 has limited vision and requires eyeglasses. On 6/30/2021, R1’s Responsible Party was informed that a replacement wristwatch was available after a change of battery. On 7/2/2021, facility staff assisted R1 to a local vendor to replace the eyeglasses.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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-20210629102735

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: VALLE VERDE	FACILITY NUMBER: 421700411
	VISIT DATE: 07/09/2021

NARRATIVE

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To date, the eyeglasses have not been located and R1 has not received a replacement of the eyeglasses and wristwatch. Based on the interviews conducted and records reviewed, the allegation that the facility failed to safeguard Resident’s belongings is Substantiated at this time.
On 6/21/2021, R1’s responsible party contacted facility staff to notify them that R1 did not have their eyeglasses or wristwatch. After R1 notified staff of the missing items, staff made various inquiries to locate the items. Based on record review and interviews conducted, facility staff did not notify R1’s responsible party of the missing items and did not notify Community Care Licensing (CCL) of the missing items. Therefore, the allegation that facility staff did not report missing items is Substantiated at this time.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D).

Exit interview conducted. Copy of report issued. Deficiencies issued. Appeal Rights issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210629102735

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: VALLE VERDE	FACILITY NUMBER: 421700411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/12/2021 Section Cited CCR 87218(a)(2)	1 2 3 4 5 6 7	87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program ... (2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value.	1 2 3 4 5 6 7	Administrator will update internal document regarding resident information to indicate resident's care needs allowing others caring for resident to address resident's health, welfare, and safety allowing missing items to be addressed promptly.
	8 9 10 11 12 13 14	...This requirement is not met as evidenced by: Based on record review and interviews, R1’s personal eyeglass and wristwatch were lost when R1 was sent to the hospital following a fall. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 07/12/2021 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified ...	1 2 3 4 5 6 7	Administrator will update internal document regarding resident information to indicate resident's care needs allowing others caring for resident to address resident's health, welfare, and safety allowing items needed for ADL to be addressed promptly.
	8 9 10 11 12 13 14	(D) Any incident which threatens the welfare, safety or health of any resident...This requirement is not met as evidence by: Based on record review and interviews, the loss of R1’s eyeglasses and wristwatch were not reported to R1’s responsible party or to CCL which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan Luong	TELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC9099 (FAS) - (06/04)

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