421700457-7-7-2022-29-AS-KBUY-CSQRXB-20230612132425

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 421700457
Report Date: 07/07/2022
Date Signed: 07/07/2022 06:26:17 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
06/28/2022 and conducted by Evaluator Kristin Kontilis

COMPLAINT CONTROL NUMBER: 29-AS-20220628153056

FACILITY NAME:	WOOD GLEN HALL, INC.		FACILITY NUMBER:	421700457
ADMINISTRATOR:	JOAN SCHUERMANN		FACILITY TYPE:	740
ADDRESS:	3010 FOOTHILL ROAD		TELEPHONE:	(805) 687-7771
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93105
CAPACITY:	72	CENSUS: 39	DATE:	07/07/2022
		UNANNOUNCED	TIME BEGAN:	12:31 PM
MET WITH:	Lourdes Espinoza, Interim Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff are not associated to the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced initial complaint inspection for the above-stated allegation(s). LPA met with Jeff LaBelle, Consultant, West Bay Senior Living, and Lourdes Espinoza, Interim Administrator and explained the purpose of the visit.
Entrance interview conducted.
During the visit, LPA conducted health and safety tour of the facility. From 12:50 pm to 4:00 pm, LPA conducted in-person interview(s) with Administrator and staff, and obtained copies of documents pertaining to the investigation.
Interviews revealed the facility subcontracts with a home care agency to provide care and supervision staffing to residents in care. LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel Report summary and home care agency’s staff schedule. LPA determined fifteen (15) of the staff from the home care agency currently work in the facility and were not associated to the facility prior to providing staffing assistance.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

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-20220628153056

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: WOOD GLEN HALL, INC.	FACILITY NUMBER: 421700457
	VISIT DATE: 07/07/2022

NARRATIVE

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LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel and facility staff roster and determined an additional eight (8) facility staff, not affiliated with a home care agency, currently work in the facility and were not associated to the facility prior to employment.

Based on record review and interviews conducted, the allegation that staff are not associated to the facility is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220628153056

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: WOOD GLEN HALL, INC.	FACILITY NUMBER: 421700457
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/08/2022 Section Cited CCR 87355(e)(1)	1 2 3 4 5 6 7	87355(e)(1) Criminal Record Clearance. (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed that staff members will not work at this facility without an appropriate transfer. Civil Penalty assessed in the amount of $11,200.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as fifteen (15) staff from a home care agency and eight (8) facility staff were not associated to work in the facility, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
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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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC9099 (FAS) - (06/04)

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