421700411-6-24-2022-29-AS-KBUY-CJRL4Z-20220930082621

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 421700411
Report Date: 06/24/2022
Date Signed: 06/24/2022 05:28:51 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
06/17/2022 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20220617165147

FACILITY NAME:	VALLE VERDE		FACILITY NUMBER:	421700411
ADMINISTRATOR:	SUSAN E PONCE		FACILITY TYPE:	741
ADDRESS:	900 CALLE DE LOS AMIGOS		TELEPHONE:	(805) 883-4193
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93105
CAPACITY:	547	CENSUS: 366	DATE:	06/24/2022
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Jeremiah Hovsepian Bearce, Director of Health Services		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility is without a first aid kits in designated areas

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced initial 10-Day complaint visit to the facility above at 12:20 PM. LPA met with Jeremiah Hovsepian Bearce, Director of Health Services and explained the purpose of the visit. Administrator Susie Ponce and Melissa Honig, Executive Director were not available at the time of the visit. LPA conducted a tour of the facility from 1:20 pm to 2:20 pm with Jeremiah Hovsepian Bearce, Director of Health Services and Stephen Freine, Building and Gounds Director.

On the allegation that the facility is without First Aid kits in designated areas of the facility, at 1:35 pm, 1:39 pm, and 1:45 pm, LPA observed First Aid kit signage indicating First Aid kits were available in the cabinets in East Laundry Room, #33 (1:35 pm), Rose-Garden Clubhouse #35 (1:39 pm), and The North Gazebo Clubhouse, #36 (1:45 pm) yet no first Aid kids were present. LPA informed Building and Grounds Director and Director of Health Services that there were no First Aid kits in the cabinets where the signage is posted. Based on LPA’s observation, the allegation that the facility is without First Aid kits in designated areas is Substantiated at this time. Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

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-20220617165147

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: 06/24/2022

NARRATIVE

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LPA asked if there were first aide kits anywhere else on campus for residents and Director of Health Services stated no but there is a call button in every clubhouse where residents can pull and a clinic nurse will come to address any issue including first aide. Facility placed first aide in every cabinet where it was listed and agreed to audit it daily. Facility will review in the upcoming weeks if they will keep the signs up and offer first aide in those locations in the future.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):
Exit interview conducted. Copy of today’s report and appeal rights were reviewed and emailed to Executive Director and Director of Health Services.

Due to Computer issues a wet signature is on file.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 29-AS-20220617165147

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: 06/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/25/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility Immediately placed new first aid kits in cabnets. The POC was cleared during the visit.
	8 9 10 11 12 13 14	Based on LPA’s observation, the licensee did not comply with the section cited above as LPA observed 3 out of 4 laundry room cabinets with First Aid kit signage posted but no First Aid kits were observed in the cabinet(s) which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC9099 (FAS) - (06/04)

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