421703635-7-22-2021-29-AS-KBUY-C57KUD-20210723081234

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 421703635
Report Date: 07/22/2021
Date Signed: 07/22/2021 04:12:41 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
08/14/2019 and conducted by Evaluator Kristin Kontilis

COMPLAINT CONTROL NUMBER: 29-AS-20190814151602

FACILITY NAME:	DANELLE'S GUEST HOME I		FACILITY NUMBER:	421703635
ADMINISTRATOR:	COMETA, NONA		FACILITY TYPE:	740
ADDRESS:	4866 FRANCES ST		TELEPHONE:	(805) 967-5237
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93111
CAPACITY:	6	CENSUS: 3	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Nona Cometa, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff failed to provide adequate food service to resident.
Facility failed to administer medications as prescribed.
Facility staff prevented resident from having a visitor.
Facility staff failed to meet the needs of a resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced complaint visit regarding the above allegations. During the investigation, LPA interviewed residents on 8/14/2019 and 7/22/2021; interviewed staff on 8/14/2019 and 7/22/2021; and interviewed resident’s family members on 8/16/2019, 8/22/2019, and 4/5/2021. LPA also collected and reviewed relevant documents on 8/14/2019 and 7/22/2021.
Allegation #1: Facility staff failed to provide adequate food service to resident. Family members stated R1 did not complaint to them about the food. R1’s Power of Attorney (POA) stated the facility staff met all of R1’s needs. LPA interviewed residents about the food. Meals are personally selected to Residents’ liking. Today’s breakfast was a choice of oatmeal with toast and fresh banana; French toast; or waffle with banana. Today’s lunch is Salisbury steak (frozen). Residents have requested tonight’s dinner to be chicken noodle soup with turkey sandwich; peanut butter and mayonnaise sandwich with banana, cookies, and ginger ale or orange juice; or pureed diet blend with Ensure.

Please continue to 9099, Pg 2.

Unsubstantiated

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: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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-20190814151602

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: DANELLE'S GUEST HOME I	FACILITY NUMBER: 421703635
	VISIT DATE: 07/22/2021

NARRATIVE

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On 08/21/2019, LPA observed the dinner meal served in the facility and observed the meals to be of the quality and quantity necessary to meet the needs of the residents. On 8/14/2019 and 7/22/2021, LPA also observed an adequate amount of perishable and non-perishable food in the facility. On 7/22/2021, LPA observed the non-perishable and perishable foods consisting of 8 bananas, 6 apples, 2 large zucchini squash, 4 tomatoes, one 12-ounce package of baby carrots, 1 package of grated cheese (32 servings), 1 package of corn tortillas (80 count), 6 flour tortillas, 18 fresh eggs, 40 slices of American cheese, 2 boxes of raisins (1 serving each), 6 servings of pudding cups, various frozen meats and meals, 1 2/3 container of pineapple/orange/banana fresh juice, and 5/6 gallon of milk (16 servings). Staff interviewed on 7/22/2021 stated R1 often sat at the kitchen counter and requested a variety of foods, particularly ice cream and ethnic dishes with rice, fish, vegetables, and special sauces. Based on observations and interviews conducted, the allegation that facility staff failed to provide adequate food service to resident is Unsubstantiated at this time.
Allegation #2: Facility staff failed to administer medications as prescribed. It was alleged that staff did not have access to the locked medication cabinet and therefore could not assist residents with their medications.
R1 was put on hospice and medications were changed by R1’s hospice physician. R1’s Power of Attorney stated R1 received medications as prescribed. R1’s POA stated the facility staff met all of R1’s needs. Based on interviews conducted and documents obtained, the allegation that facility staff failed to administer medications as prescribed is Unsubstantiated at this time.
Allegation #3: Facility staff prevented resident from having a visitor. Based on resident, family members, and staff interviews, staff did not prevent Resident 1 (R1) from having a visitor. R1’s family member contacted visitors and asked the visitors not to visit R1. Based on the request from the family member, the visitors did not make further attempts to visit R1 at the facility. The facility staff did not deny R1 visitation with visitors, therefore the allegation has been Unsubstantiated at this time.
Allegation #4: Facility staff failed to meet the needs of a resident. It was alleged that Resident 1 (R1)’s catheter was “crusty” and leaked. R1 was receiving hospice services which included care for R1’s catheter. The reporting party stated hospice nurses did not respond timely when R1 experienced issues with the catheter. The issues reported by the reporting party were issues not related to facility staff, but to the outside hospice agency. Based on the information ob

tained, the allegation has been Unsubstantiated at this time

Administrator Nona Cometa was unavailable to sign the report and requested Marino “Mark” Jose, Assistant Administrator to sign the report on her behalf.

Exit interview conducted. No citations issued. A copy of this report has been emailed.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

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