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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421703604
Report Date: 12/03/2021
Date Signed: 12/03/2021 04:13:13 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
12/02/2021 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20211202163009
FACILITY NAME:ORCUTT BOARD AND CARE HOMEFACILITY NUMBER:
421703604
ADMINISTRATOR:ANNIE YAGUEFACILITY TYPE:
740
ADDRESS:263 CRESCENT AVE.TELEPHONE:
(805) 934-2586
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:6CENSUS: 3DATE:
12/03/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Annie Yague, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Facility is inadequately staffed
INVESTIGATION FINDINGS:
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On 12/3/21 at 10:00 AM, Licensing Program Analyst (LPA) Toan Luong conducted an unannounced 10-day complaint visit to the facility. LPA met with Administrator Annie Yague and explained the purpose of the visit.

During the visit, LPA toured the facility to perform a safety and welfare check. LPA interviewed staff and resident. Interviews reveals that at approximately after 11:39 PM on 11/20/2021, police arrived at the facility after receving a 9-1-1 call. No one responded at the door when police arrived. Police pushed the double door open as the doors were not securely latched and wanted to ensure the safety of the household due to the nature of the call. Police announced their presence and were not able to locate a staff for sometime after continuously annoucning presence loudly. After sweeping through the facility, police knocked loudly on a door, and a staff responded. Staff did not respond to resident's call button as staff's shift ended at 8:00 PM. Other caregiver had left the facility. Call button rings loudly throughout the facility, but on call caregiver was wearing headset and did not respond to call button. Interviewees estimate call button was not responded in a range from 20 to 30 minutes. (continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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 3
Control Number 29-AS-20211202163009
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: ORCUTT BOARD AND CARE HOME
FACILITY NUMBER: 421703604
VISIT DATE: 12/03/2021
NARRATIVE
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The allegation is deemed to be substantiated at this time.
Exit interview was conducted with Administrator, citation issued, appeal rights and a copy of the report will be emailed to administrator
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20211202163009
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: ORCUTT BOARD AND CARE HOME
FACILITY NUMBER: 421703604
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/03/2021
Section Cited
CCR
87415(a)(1)
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87415 Night Supervision (a) The following persons providing night supervision...(1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises.This requierment was not met by: Based on interviews, the facility did not have staff on call to respond to emergency personel nor
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Staff involved will be retrained. Staff will communicate coverage. Facility will also provide contact information to residents.
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resident in a timely manner.
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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: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3