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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 421703604
Report Date: 12/23/2021
Date Signed: 12/23/2021 11:34:47 AM



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
12/21/2021 and conducted by Evaluator Toan Luong
COMPLAINT CONTROL NUMBER: 29-AS-20211221143206
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:
12/23/2021
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator Annie YagueTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility failed to report a resident fall to the residents representatives
INVESTIGATION FINDINGS:
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On 12/23/21 at 9:50 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 and obtained documents pertient to the investigation. On 12/9/21, Resident 1 (R1) fell and was taken to the ER by facility staff. R1 was diagnosed with a fracture on the left fibula. Administrator stated that a friend of R1 was notified. Administrator stated the friend receives finanial compensation from R1's representative, and as a result, administrator believed the friend would have notified R1's representative and fulfill the facility's reporting requirement. CCLD does not have a written record of the incident. Administrator stated that an Incident Report was forgotten and not submitted. LPA explained a written report is required to responsible party and to CCLD. Based on interview and documentation, the above allegation is deemed to be substantiated at this time. LPA issued citation on LIC 9099-D, conducted exit interview, and emailed appeal rights and report to administrator.
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: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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 2
Control Number 29-AS-20211221143206
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: 12/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2021
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: Any incident which threatens the welfare, safety or health of any resident.This requirement is not
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Administrator will submit incident report and a letter acknowledging that a written report will be submitted to the responsible party and to CCLD.
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met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as an incident report was not submitted to CCLD nor R1's responsible party, which posed a potential 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: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
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