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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421703604
Report Date: 06/12/2024
Date Signed: 06/12/2024 12:40:04 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
12/01/2023 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20231201163837
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: 6DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Annie Yague, Licensee/AdministratorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff mismanaged resident’s medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Phillips met with Licensee/Administrator Annie Yague and explained the reason for the visit.

On 12/01/2023, the Department received a complaint alleging facility staff mismanaged Resident #1’s (R1’s) medications by over-medicating R1.

On 12/05/2023, from 10:00am to 4:00pm, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct an initial complaint visit. LPA Phillips met with licensee/administrator Annie Yague and announced the purpose of the visit. The LPA conducted a physical tour, requested documents, LPA observed and photographed facility food supply, resident bedrooms, and common areas (kitchen, dining room, living room, bathrooms). The LPA determined further investigation was needed prior to issuing findings. Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
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 9
Control Number 29-AS-20231201163837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ORCUTT BOARD AND CARE HOME
FACILITY NUMBER: 421703604
VISIT DATE: 06/12/2024
NARRATIVE
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On the allegation: Staff mismanaged resident’s medication. According to R1’s physician report, signed and dated 03/30/2023, the primary diagnosis was listed as dementia. R1 was not identified with motor impairment or paralysis. R1 was identified as being confused/disoriented, with wandering behavior, sundowning behavior, but was listed as being able to follow instructions and communicate needs. R1 was listed as ambulatory and could independently transfer to and from bed. The report documented R1 was able to dress, groom, feed self, and care for own toileting needs. The resident appraisal information, dated 03/30/2023, indicated R1 had moderate dementia, used a walker, was listed as non-ambulatory, but did not need help transferring in and out of bed or chair. Facility records indicated R1 was admitted to the facility on 04/01/2023.

R1’s Centrally Stored Medication Record (CSMR) was reviewed. The record lists three (3) dates filled (04/07/2023, 04/22/2023, and 05/06/2023) for the medication Quetiapine 50 mg. The instructions on the record are listed as “take 1-2 tabs at bedtime as needed”. “As needed” indicates that this medication was prescribed as a PRN (Pro re nata). The facility did not have a specific order for an exact dosage for R1’s PRN (as needed) Quetiapine medication and should have clarified the order with R1’s physician. A review of the facility’s “As Needed Medication Record” dated 04/07/2023, revealed that R1 was being given a dose of Quetiapine 50 mg routinely every night at bedtime, and not as prescribed on an “as needed” basis. Some of the entries are listed with doses of 50 mg, other dates and doses indicate 100 mg was given. The record listed the Quetiapine as being given routinely at every bedtime, with an “effectiveness” consistently noted as “calm” or “sleeping”. These records are dated from 04/07/2023 through 07/27/2023. This indicates that during this time period, the facility staff gave R1 a PRN Quetiapine as a routine daily medication and not as ordered as a PRN, which should have only been given on an as needed basis. Later, R1’s physician changed the Quetiapine dosage to 75 mg, citing that 100mg (2 tabs) was too much for the resident and causing them to be to sleepy.

Based on the information obtained, there was sufficient evidence to show R1’s medication was not given as prescribed. Therefore, the allegation is deemed Substantiated at this time.

Exit interview, deficiencies cited on 9099-D, report given, appeal rights given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 29-AS-20231201163837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/13/2024
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by:
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Licensee will submit a plan how you will ensure medication is given according to the physician's directions. Submit to CCL by 6/13/2024

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Based on records review, the licensee did not comply with the section cited above when staff gave R1 PRN Quetiapine as a routine daily medication and not as ordered, which posed 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: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
12/01/2023 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20231201163837

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: 6DATE:
06/12/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Annie Yague, Licensee/AdministratorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff neglect led to resident sustaining fractures while in care.
Due to neglect, resident sustained UTI while in care.
Staff did not make sure resident's room was kept clean.
Staff did not provide adequate food service.
Staff did not comply with resident's admission agreement.
Facility is in disrepair.
Staff did not provide activities for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Annie Yague and explained the reason for the visit.

On 12/01/2023, the Department received a complaint alleging that facility staff failed to provide an appropriate level of supervision resulting in Resident 1 (R1) falling on two occasions, sustaining a spinal fracture, a fractured femur and bruising. It was also alleged that due to staff neglect R1 sustained a Urinary Tract Infection (UTI) while in care. The complaint was referred to the Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Douglas Real.

On 12/05/2023, from 10:00am to 4:00pm, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility unannounced to conduct an initial complaint visit. LPA Phillips met with licensee/administrator Annie Yague and announced the purpose of the visit. Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 29-AS-20231201163837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ORCUTT BOARD AND CARE HOME
FACILITY NUMBER: 421703604
VISIT DATE: 06/12/2024
NARRATIVE
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The LPA conducted a physical tour, requested documents, LPA observed and photographed facility food supply, resident bedrooms, and common areas (kitchen, dining room, living room, bathrooms). The LPA determined further investigation was needed prior to issuing findings. Investigator Real conducted interviews on 12/15/2023, at approximately 3:30pm, with Resident #1’s (R1’s) resident representative; on 01/08/2024, from approximately 4:10pm to 7:10pm, with facility staff and residents; and on 02/05/2024, at approximately 12:00pm, with the administrator. In addition, the investigator reviewed medical records from Marian Regional Medical Center, American Medical Response (AMR) ambulance, and facility file documents related to R1.

According to R1’s physician report, signed and dated 03/30/2023, the primary diagnosis was listed as Dementia. R1 was not identified with motor impairment or paralysis. R1 was identified as being confused/disoriented, with wandering behavior, sundowning behavior, but was listed as being able to follow instructions and communicate needs. R1 was listed as ambulatory and could independently transfer to and from bed. The report documented R1 was able to dress, groom, feed self, and care for own toileting needs. The resident appraisal information, dated 03/30/2023, indicated R1 had moderate dementia, used a walker, was listed as non-ambulatory, but did not need help transferring in and out of bed or chair. Facility records indicated R1 was admitted to the facility on 04/01/2023.

On the allegation: Staff neglect led to resident sustaining fractures while in care. R1’s medical records indicated R1 was admitted to Marian Regional Medical Center on 07/31/2023 after an unwitnessed fall. R1 sustained a laceration to the right front orbital region. No acute fractures were identified. A CT scan of the spine revealed severe degenerative changes and it was noted R1 had multiple chronic cervical spine compression fractures. Osteoarthritis was also noted in the records. A chest x-ray showed possible pneumonia, that was addressed with antibiotics, and R1 was discharged back to the facility. On 08/11/2023, R1 returned to the hospital for complaint of back pain. A CT scan of R1’s spine revealed a previously unidentified spinal fracture from 01/22/2023.

On 10/26/2023, R1 had a witnessed fall that resulted in no visible injuries and R1 denied any injuries or pain. The following day, 10/27/2023, R1 was sent to the hospital after loss of consciousness at the dining table. At the hospital R1 was initially diagnosed with a UTI and on 10/31/2023 was found to have a periprosthetic femur fracture. On 11/01/2023, R1’s resident representative declined surgical intervention and R1 was placed on hospice and discharged to a skilled nursing facility.
Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 29-AS-20231201163837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ORCUTT BOARD AND CARE HOME
FACILITY NUMBER: 421703604
VISIT DATE: 06/12/2024
NARRATIVE
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The investigation included a review pertaining to periprosthetic femur fractures. According to the National Institutes of Health (NIH), the fractures usually occur as a result of minor trauma, and people with osteoporosis are at risk. Some fractures present with pain and inability to ambulate, while some present with vague thigh pain but are able to ambulate. The investigation further revealed R1’s resident representative did not witness any neglect or harm by any of the facility staff. The residents had no neglect concerns and felt the staff provided an appropriate level of care and supervision. The staff and the licensee denied providing inadequate care that led to the fracture.

Based on interviews and records review, the Department does not have sufficient evidence to determine that there was negligence or lack of supervision on behalf of the facility staff. Although R1 did sustain fractures while in care, there is insufficient evidence to conclude that it was due to neglect on the part of facility staff. Therefore, the allegation “Staff neglect led to resident sustaining fractures while in care” is deemed Unsubstantiated at this time.

On the allegation: Due to neglect resident sustained UTI while in care. On 10/26/2023, R1 had a witnessed fall that resulted in no visible injuries and R1 denied any injuries or pain. The following day, 10/27/2023, R1 was sent to the hospital after loss of consciousness at the dining table. The hospital records noted the chief complaint as a syncopal episode while in wheelchair. At the hospital R1 was diagnosed with a UTI. The medical records reviewed did not indicate any signs of neglect. The investigation further revealed R1’s resident representative visited R1 in the facility and observed the facility staff interaction with the residents and denied seeing any intentional harm or neglect by the staff. Per documents reviewed, R1 did not require staff assistance with toileting.

Based on interviews and records review, there is insufficient evidence to prove the alleged violation occurred. Although R1 sustained a UTI while in care, there is insufficient evidence to conclude that the UTI was a result of staff negligence. Therefore, the allegation “Due to neglect resident sustained UTI while in care” is deemed Unsubstantiated at this time.

On the allegation: Staff did not make sure resident's room was kept clean. It was alleged a resident’s room was not clean, as there were spiders in the room. LPA toured the facility on 12/5/2023 and took photographs. LPA did not observe any spiders or that the facility was unclean. Residents interviewed indicated the facility was clean. During the visit, LPA also observed facility staff cleaning. Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 29-AS-20231201163837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ORCUTT BOARD AND CARE HOME
FACILITY NUMBER: 421703604
VISIT DATE: 06/12/2024
NARRATIVE
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Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff did not provide adequate food service. It was alleged staff served juice instead of water, only served processed foods, served cold food, and did not serve food in a timely manner. On 12/5/2023, LPA observed the facility food supply. LPA observed a supply of fresh fruit on the counter accessible to residents, and a water dispenser. In the refrigerator, LPA observed an adequate amount of food including milk, juice, coffee creamer, fruit, bread, cheese, lunchmeat, vegetables, meat, and condiments. In the freezer, LPA observed ice cream, tempura shrimp, frozen meals, fries, frozen vegetables, and frozen meat. The facility also had an adequate supply of nonperishable foods. Through interviews with Staff, LPA was told the facility follows a documented daily menu for residents, unless a substitution regarding recipes and/or ingredients needs to be made. This includes providing water to a resident instead of juice, coffee, milk, etc. as stated on the facility daily menu. LPA requested and received a copy of the facility daily menu which provided a weekly schedule of meals for breakfast, lunch, and dinner. The facility daily meal menu provides different foods for each meal of the day and provides different foods daily to residents. The daily menu provides meals that are not processed foods and meals that are served warm/hot. All residents interviewed by LPA had no corroborative statements about the food service at the facility. No resident interviewed stated that water was not served, the facility only served processed foods, only served cold food, and did not serve food in a timely manner.

Based on interviews, records review, and LPA observations, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation “Staff did not provide adequate food service.” is deemed Unsubstantiated at this time.

On the allegation: Staff did not comply with resident's admission agreement. It was alleged that although Resident 1 (R1)’s admission agreement stated it would be a private room and bathroom, other residents used R1’s bathroom. LPA requested and received signed copies of R1’s admission agreement and the facility house rules. Through record review, the dated and signed admission agreement of R1 does not mention anything about a private bathroom. The admission agreement states that the lodging is a private, non-ambulatory room, with no mention of a private bathroom for R1. LPA observed two (2) resident bathrooms in the facility. Both bathrooms were in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 29-AS-20231201163837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ORCUTT BOARD AND CARE HOME
FACILITY NUMBER: 421703604
VISIT DATE: 06/12/2024
NARRATIVE
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Through Staff interviews, LPA was told that the resident restrooms are communal as the facility has six (6) residents in care, so therefore residents have to share bathrooms. One of the bathrooms in the facility has 2 doors on either side and is a "jack and jill style" restroom so residents can enter the restroom from either side. One of the doors on this bathroom is connected to a resident bedroom, but the other door of the bathroom is connected to a different room in the facility. Therefore, a resident can enter that bathroom from their bedroom and other residents can enter the bathroom from the other side when it is unoccupied. There is no evidence that any resident invaded R1’s personal space by entering the communal restroom through the door in R1’s private bedroom.

Based on interviews, records review, and LPA observations, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation “Staff did not comply with resident's admission agreement” is deemed Unsubstantiated at this time.

On the allegation: Facility is in disrepair. It was alleged the facility had a ramp that was not installed properly which caused a resident to trip. LPA observed a ramp in the facility from the hallway to a living room. The ramp is carpeted, but the carpet was not tight and had ripples in it. LPA observed a second ramp from the hallway into the dining room/kitchen area of the facility. This ramp was also carpeted, and LPA did not observe any ripples in the carpet. All Staff interviewed by LPA denied that any residents have ever tripped on the uneven carpet. LPA interviewed residents about the use and safety of the carpet on the ramp(s), but no resident told LPA that they had personally tripped on either of the ramps or witnessed any other resident trip on the carpet of the ramp. Staff agreed to a request by LPA to adjust the carpet of the ramp from the hallway into a living room, so the ripples aren’t there.

Based on interviews and LPA observations, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation “facility is in disrepair” is deemed Unsubstantiated at this time.

On the allegation: Staff did not provide activities for residents. It was alleged the facility did not provide any activities. LPA observed activities in the facility including puzzles, games, and residents watching television. Residents interviewed by LPA indicated that they liked activities in the facility including watching television shows with other residents, playing crossword puzzles at the dining room table, and reading books.
Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 29-AS-20231201163837
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ORCUTT BOARD AND CARE HOME
FACILITY NUMBER: 421703604
VISIT DATE: 06/12/2024
NARRATIVE
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LPA requested and received copies of the facility admission agreement and the facility house rules. The facility admission agreement states there are planned activity programs for residents, and the facility house rules states that residents are allowed televisions and/or radios in their own bedrooms as well as a shared television available for viewing in the living room of the facility. Staff interviews by LPA indicated that residents are provided crossword puzzles, reading materials, and a television in the living room that residents watch together. Residents are also provided jigsaw puzzles to complete alone or with other residents under the supervision of Staff.

Based on interviews, records review, and LPA observations, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation “Staff did not provide activities for residents” is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9