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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421703748
Report Date: 07/22/2021
Date Signed: 07/22/2021 03:27:38 PM

Document Has Been Signed on 07/22/2021 03:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:PURISIMA HILLSFACILITY NUMBER:
421703748
ADMINISTRATOR:SUSAN MARSHFACILITY TYPE:
740
ADDRESS:237 ALDEBARAN AVENUETELEPHONE:
(805) 733-4395
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 6CENSUS: DATE:
07/22/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sue Marsh, Licensee/AdministratorTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Chavez conducted a Case Management – Deficiencies visit to issue additional deficiencies found during LPA Kontilis’ investigation of complaint 29-AS-20190702152123. LPA met with Sue Marsh, Administrator, and explained the purpose of the visit.

During LPA Kontilis’ investigation of complaint 29-AS-20190702152123, interviews revealed Licensee/Administrator cancelled Resident 1 (R1)’s medical appointment without R1’s consent or authorization. R1 had previously expressed to Licensee/Administrator that R1 did not want Licensee/Administrator attending R1’s medical appointments. Licensee/Administrator rescheduled R1’s follow-up medical appointment due to it being scheduled at an “inconvenient” time for Licensee/Administrator to attend. Licensee/Administrator stated to R1 she was required to be present at the appointment. Interviews conducted and records reviewed revealed R1 did not sign an acknowledgement granting consent to have Licensee/Administrator present during medical appointments. Based on the evidence obtained, the Licensee/Administrator violated R1’s personal rights by cancelling R1’s medical appointment without consent.

Exit interview, deficiency cited on 9099-D, report emailed, appeal rights emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2021 03:27 PM - It Cannot Be Edited


Created By: Darlene Chavez On 07/22/2021 at 09:19 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PURISIMA HILLS
FACILITY NUMBER: 421703748

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2021
Section Cited
CCR
87468.1(a)(16)

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87468.1(a)(16) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services. This requirement is not met as evidenced by:
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Licensee/Administrator agrees to read and review CCR 87468.1 in its entirety and will submit a written statement to CCL acknowledging compliance of the said regulation.

POC received on 10/30/2020.
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Based on interviews, the licensee did not allow R1 the personal right to reject the service of the licensee/administrator accompanying R1, which posed a potential person right 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 Burley
LICENSING EVALUATOR NAME:Darlene Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2021


LIC809 (FAS) - (06/04)
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