425801658-3-13-2023-29-AS-KBUY-CQD4YS-20230328193138

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801658
Report Date: 03/13/2023
Date Signed: 03/13/2023 11:36:59 AM

Unsubstantiated

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
01/31/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230131154556

FACILITY NAME:	LE-NA' RESIDENTIAL #5		FACILITY NUMBER:	425801658
ADMINISTRATOR:	ESTELLA USHER		FACILITY TYPE:	735
ADDRESS:	1448 WEST CALLE MARGARITA		TELEPHONE:	(805) 287-9473
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY:	4	CENSUS: 3	DATE:	03/13/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Estella Usher, Administrator		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility staff refuse to provide resident food.
Facility staff falsifying sign in and sign out sheet.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA conducted the investigation with Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa and interviewed a Witness on 2/1/23, Staff and clients on 2/2/23, Staff 2 on 3/7/23, and Service Coordinator on 3/7/23. LPA met with Administrator and explained the purpose of the visit.

On the allegation: Facility staff refuse to provide resident food. It was alleged on 1/27/23 Client 1 (C1) asked Staff 1 (S1) for something to eat and S1 refused. LPA and QAS interviewed client who said they asked Staff 1 for something to eat and Staff 1 refused. LPA and QAS asked what day this happened and C1 said it happened on 1/20/23, because it happened on the same day as another incident that occurred. When asked why, C1 stated because they had a bad attitude. LPA and QAS interviewed Client 2 (C2) if they ever were denied food or saw another resident denied food.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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-20230131154556

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: LE-NA' RESIDENTIAL #5	FACILITY NUMBER: 425801658
	VISIT DATE: 03/13/2023

NARRATIVE

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C2 stated no and staff always makes clients food when asked. LPA and QAS interviewed Administrator and 2 staff who stated staff never deny clients food. Staff stated C1 is independent and knows how to make themselves a sandwich or cereal and is always allowed to go into the kitchen and get food. LPA observed an adequate supply of food that was accessible to clients in the kitchen. LPA reviewed C1’s Individual Service Plan, which indicates that C1 has fabricating stories/lying listed as a behavior. LPA and QAS interviewed C1’s Service Coordinator about the allegation and they stated that based on what they know about the facility and Administrator they have never had this concern and don’t see the home depriving or taking away food from clients. Based on interviews, the allegation is Unsubstantiated at this time.

On the allegation: Facility staff falsifying sign in and sign out sheet. It was alleged the sign in and sign out sheets for Client 1 are false and the facility is forging them showing C1 working with a specialist when in fact C1 was somewhere else and staff “mess with the timesheet”. The reporting party stated they wanted to see how often the facility uses the behaviorist and observed visitor logs that did not match up with the services being provided. LPA and QAS interviewed Administrator who stated that sometimes staff forget to have visitor’s sign in or forget to have C1 sign out when they leave on outings so it’s not always accurate. LPA and QAS interviewed C1’s Service Coordinator about the Visitor Log and they had no concerns regarding the facility not meeting with the Behaviorist or not having “accurate” logs. LPA reviewed PIN 22-28-ASC dated 9/26/22 that states it is a “Best Practice” to screen Visitors for symptoms of COVID-19 and do a temperature check but does not state requirements about Visitors signing in. The previous PIN 22-07-ASC states it’s a “Best Practice” to record name and contact information for individuals entering the facility for possible contact tracing at a later date. Based on the information obtained the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report was emailed and printed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC9099 (FAS) - (06/04)

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