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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421702010
Report Date: 11/18/2021
Date Signed: 11/18/2021 03:11:12 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
08/27/2021 and conducted by Evaluator Arien Diaz
COMPLAINT CONTROL NUMBER: 29-AS-20210827102315
FACILITY NAME:QUEJA RESIDENTIAL FACILITY FOR THE ELDERLYFACILITY NUMBER:
421702010
ADMINISTRATOR:QUEJA, DOROTHYFACILITY TYPE:
740
ADDRESS:845 PATTERSON ROADTELEPHONE:
(805) 934-3702
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 3DATE:
11/18/2021
UNANNOUNCEDTIME BEGAN:
11:26 AM
MET WITH:Dorothy QuejaTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility did not follow COVID-19 precautions.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Diaz conducted a complaint visit to deliver final findings of the complaint investigation conducted by LPA Diaz.

LPA Diaz reviewed facility documents and conducted interviews with staff residents and family member. LPA interviewed staff on 09/01/21 at 12:50pm, 1:33pm, 1:38pm, 2:00pm. LPA interviewed residents on 09/01/21 at 1:51pm. LPA interviewed family members on 09/04/21 at and 1:09pm and on 09/23/21 at 3:41pm. On the allegation: Facility did not follow COVID-19 precautions. LPA arrived at the facility on 09/01/21 at 12:15pm. LPA was greeted to enter the facility by staff 1 (S1). LPA informed S1 that visitors must be screened before entering the facility. According to the administrator, all staff wear masks inside the facility and the staff screen visitors before entering the facility. LPA observed the administrator instruct 3 staff members to screen visitors before entering the facility during the LPAs visit. LPA toured the facility and conducted interviews with the staff. 3 out of 3 staff stated that all visitors are screened before entering the facility and all staff members wear face masks inside the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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-20210827102315
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: QUEJA RESIDENTIAL FACILITY FOR THE ELDERLY
FACILITY NUMBER: 421702010
VISIT DATE: 11/18/2021
NARRATIVE
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Resident 2 (R2) stated they do not remember or notice if staff members wear facemasks inside the facility. According to the resident family member, the staff allowed the family member inside the facility without taking their temperature or ask screening questions. LPA toured the facility and observed a hairstylist cutting a resident’s hair at 1:10pm. According to the hairstylist, they were greeted inside the facility by S1 without being screened. At 2:10pm LPA observed a nurse enter the facility. The nurse stated that the facility staff screen visitors and log the information. LPA reviewed the 2021 visitor log for September July and August and verified that the facility did not document 19 visitor’s temperatures. LPA also verified that the nurse’s temperature and screening questions were not documented in the visitor log on 09/01/21. The facility did not implement a sign-in policy for all visitors to ensure compliance with one central entry point for COVID-19 symptom screening and to record contact information in case needed for reporting requirements or contact tracing. Based on the evidence gathered through interviews and records reviewed, the allegation is deemed substantiated at this time.

Exit interview, dfeiciency cited, report given, appeal rights given.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
08/27/2021 and conducted by Evaluator Arien Diaz
COMPLAINT CONTROL NUMBER: 29-AS-20210827102315

FACILITY NAME:QUEJA RESIDENTIAL FACILITY FOR THE ELDERLYFACILITY NUMBER:
421702010
ADMINISTRATOR:QUEJA, DOROTHYFACILITY TYPE:
740
ADDRESS:845 PATTERSON ROADTELEPHONE:
(805) 934-3702
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 3DATE:
11/18/2021
UNANNOUNCEDTIME BEGAN:
11:26 AM
MET WITH:Dorothy QuejaTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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2
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9
Facility illegally evicted resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Diaz conducted a complaint visit to deliver final findings of the complaint investigation conducted by LPA Diaz.

LPA Diaz reviewed facility documents and conducted interviews with staff residents and family member. LPA interviewed staff on 09/01/21 at 12:50pm, 1:33pm, 1:38pm, 2:00pm. LPA interviewed residents on 09/01/21 at 1:51pm. LPA interviewed family members on 09/04/21 at and 1:09pm and on 09/23/21 at 3:41pm. On the allegation: Facility illegally evicted resident. According to the administrator, resident 1 (R1) was not evicted and the family wanted to take R1 back home. The administrator advised to the family that it would be challenging to provide care for R1 and the administrator suggested moving R1 into a skilled nursing facility. The family asked for a full refund and the administrator returned the family’s original check in the amount of $625.00. Staff stated R1 returned home with family. According to the family member, R1 was not evicted from the facility but was relocated to a different facility by R1s family. Based on the interviews, the allegation for Facility illegally evicted resident is deemed unsubstantiated at this time. Exit interview, report given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20210827102315
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: QUEJA RESIDENTIAL FACILITY FOR THE ELDERLY
FACILITY NUMBER: 421702010
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited
CCR
87468.1(a)(2)
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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:
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Administrator will ensure sign in check sheet is being used going forward and will retrain staff regarding covid precautions.
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Based on interview and observation, the licensee did not ensure all persons entering the facility were screened before entering the facility, which poses an immediate health and safety 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: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4