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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421700411
Report Date: 06/10/2022
Date Signed: 06/10/2022 11:59:33 AM

Unsubstantiated


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
04/16/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210416110128
FACILITY NAME:VALLE VERDEFACILITY NUMBER:
421700411
ADMINISTRATOR:SUSAN E PONCEFACILITY TYPE:
741
ADDRESS:900 CALLE DE LOS AMIGOSTELEPHONE:
(805) 883-4000
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY:547CENSUS: 366DATE:
06/10/2022
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Jeremiah Hovsepian Bearce, Director of Health ServicesTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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Staff did not safeguard residents personal belongings
Staff denied resident their personal belongings
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted subsequent visit to deliver final findings. LPA met with Jeremiah Hovsepian Bearce, Director of Health Services and explained the purpose of the visit. Licensing Program Analysts (LPA) Toan Luong and Darlene Chavez conducted initial visit on 4/19/2021 and met with Administrator Susan Ponce. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures, the complaint investigation was conducted virtually. LPAs conducted interviews with the administrator and requested documents pertinent to the investigation. LPA Luong conducted interviews with staff, residents, and witnesses on 5/7/21, 5/11/21, 5/13/21, 8/23/21, 8/27/21, 8/31/21, and on 11/05/21. LPA Luong reviewed facility documents.

R1 was scheduled to move to assisted living from independent living on 3/23/2020. The resident and resident’s responsible parties would be responsible for the relocation of the resident.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
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 4
Control Number 29-AS-20210416110128
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: 06/10/2022
NARRATIVE
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On 3/19/2020, the Governor of California issued an order for Californian residents to stay at home to reduce the spread of the Corona Virus Disease and allowing only essential outings. Due to the Governor’s order, the facility assigned a staff/social worker (S1) to R1 to facilitate the move to assisted living. R1’s assisted living quarter was smaller in size than that of the independent living. During the initial stages of the pandemic, donations were not being accepted by charities.

Allegation #1 Staff did not safeguard resident’s personal belongings: It was alleged that R1’s belongings were not safeguarded between 3/23/2020 and afterwards during R1’s transition from independent living to assisted living. LPA Luong’s interviews reveal that Witness #1 (W1), Witness #2 (W2), and Witness #3 (W3) were packing R1’s belonging into boxes prior to the move to assisted living. W1, W2, and W3 considered themselves as close friends of R1. W3 was also the personal assistant to R1. However, interviews revealed that R1 had a falling out and did not trust W3. Statements made from R1 included, “announced what W3 would wanted of my belonging,” “Don’t come in and tell a 94, who could drop off. Don’t talk to people my age wanting my belonging,” and “No longer friends” with W3. W1, W2, and W3 had arranged for a storage unit for R1’s belongings to be transferred to. The storage unit was paid for by R1 but was listed under W3’s name. R1 did not want to release items into the storage unit. To accommodate R1, the facility used a closet in the administration wing to store R1’s belongings. R1’s independent living was described by interviewees as “Not a hoarder but does have books and newspaper stacked ceiling high.” As a result, not all of R1’s belongings could be brought over from R1’s independent living to assisted living immediately. Items would be stored in the administration closet and moved gradually to the assisted living as space was organized. Not all of R1’s items would fit in R1’s new quarters and some items would have to be donated or discarded. R1 had a book collection that was agreed to be donated to a charity. However, LPA contacted the charity and was informed that between the periods of April 2020 through August 2020, if callers were to request a donation of large quantity of books, then the charity representative would request the caller from refraining from donations at the time. However, the representative also stated that if an individual was to drop off books at the location site, there was not a sign to discourage donations. Books were reportedly donated to another organization. Other furniture items were donated to La Tienda, the facility’s store. La Tienda did not accept all furniture items and some were discarded. Interviews reported that S1 went through items with R1 for consent to be discarded or removed. R1 was also described as having poor short-term memory but good long-term memory, being disorganized, and discombobulated.
Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20210416110128
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: 06/10/2022
NARRATIVE
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 It was also learned that W3 had given W3 a raise from $15 to $30 per hour without the consent of R1. Interview with R1 revealed that R1 was afraid of jewelry being stolen. R1 would hide jewelry inside medicine bottles and stuff the bottle with hair ties to prevent any rattling sounds. R1 would then hide the medicine bottles in various furniture and beds. R1 stated that R1 wanted to keep W3 out of the moving process. R1 also stated that R1 was paranoid during the move. Interviews also revealed that W1, W2, and W3 were not familiar with each other nor with other R1’s friends until the transition process of R1.
LPA reviewed document Resident Intent to Movesigned 3/3/20 by R1. LPA reviewed document Level of Care Transfer Noticedated 3/3/20. Documents recorded that discussion for transfer was made on 7 different days between 2/13/20 through 3/1/20. Both documents were signed by R1 with the representative party left blank. LPA reviewed Storage Rental Agreement dated 3/19/20. Storage unit was under W3’s name, but did not have an indicator of where payment originated from. On 8/27/21, LPA reviewed LIC 621 Client/Resident Personal Property and Valuables signed 3/23/20 by R1. Document indicated that R1 did not want to list any items on the document. LPA reviewed email correspondence between the facility staff and W2. Email correspondence reported that “I have sorted through and am keeping her memorabilia and good jewelry, as well as R1 parents’ wedding clock, for now, until I’m able to return all in person.” LPA reviewed document SB SOS LLC Services Proposal signed by the Administrator Ponce 4/8/20. Document reported service completed were: Clients needs books cleared from property and pack photograph albums into smaller manageable boxes for storage within client’s new residence. Document does not specify details of quantity of books nor location of book donation. R1 did not complete an inventory list of items, and the facility tried to assist R1 with moving and storing their property during the pandemic. Based on the evidence obtained, the allegation is deemed unsubstantiated at this time.

Allegation #2 Staff denied resident their personal belongings: It was alleged that R1 did not have access to belongings during the transition moving to assisted living. LPA Luong’s interviews reveal that R1 would request for items. Some items were provided but other items could not be produced. Some of those items included a corral ring and a sapphire ring. Interview also revealed that R1 was described as having poor short-term memory. Interview with R1 revealed that R1 was afraid of jewelry being stolen. R1 would hide jewelry inside medicine bottles and stuff the bottle with hair ties to prevent any rattling sounds. R1 would then hide the medicine bottles in various furniture and beds. R1 stated that R1 wanted to keep W3 out of the move.
Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 29-AS-20210416110128
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: 06/10/2022
NARRATIVE
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LPA reviewed internal facility email correspondence dated 8/5/20. Email correspondence was between facility staff and indicated items were difficult to find, but in one instance, a dvd with sentimental value was found and provided. Interviews conducted with administrator indicated that this item was of importance to R1 but was misplaced several times by R1. On 8/27/21, LPA reviewed LIC 621 Client/Resident Personal Property and Valuables signed 3/23/20 by R1. Document indicated that R1 did not want to list any items on the document. LPA reviewed email correspondence between the facility staff and W2. Email correspondence reported that “I have sorted through and am keeping her memorabilia and good jewelry, as well as R1 parents’ wedding clock, for now, until I’m able to return all in person.” R1 did not list any belongings on the LIC 621 Client/Resident Personal Property and Valuables and was hiding valuables in various furniture. W2 was safeguarding some of R1’s valuables but did not provide a list. Based on the evidence obtained, the allegation is deemed unsubstantiated at this time.

Exit interview conducted and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4