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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801936
Report Date: 03/21/2022
Date Signed: 03/21/2022 11:47:04 AM

Substantiated


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
03/10/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220310155238
FACILITY NAME:BAUER RESIDENTIAL SANTA MARIA 4FACILITY NUMBER:
425801936
ADMINISTRATOR:MOSHE DAVISFACILITY TYPE:
735
ADDRESS:572 INGER DRIVETELEPHONE:
(714) 306-4068
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 4DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Moshe Davis, AdministratorTIME COMPLETED:
11:50 AM
ALLEGATION(S):
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Staff did not ensure resident attended scheduled doctor's appointments.
Staff did not ensure resident completed ordered medical testing timely.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to issue final findings. LPA met with Moche Davis, Administrator and explained the purpose of the visit. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist Vincent Figueroa. LPA interviewed credible witnesses on 3/14/22 at 12:45pm, and on 3/17/22 at 12:45pm. LPA interviewed Administrator on 3/16/22 at 3:30pm and 3/21/22 at 10:30 AM and the Licensee on 3/16/22 at 5:15pm. LPA interviewed Physician 3/18/22 at 9:00AM and LPA reviewed emailed records obtained on 3/14/22 and 3/17/22.

On the allegation: Staff did not ensure resident attended scheduled doctor's appointments. Email records show Client 1 (C1) missed a scheduled tele-medical appointment on 1/11/22 at 3:00pm. C1’s physician called the Administrator twice and left a message indicating refills on C1’s medications would not be approved until the appointment was completed. On 1/11/22, C1’s Service Coordinator emailed the Administrator to reschedule the appointment timely, since the refills would not be approved.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
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 3
Control Number 29-AS-20220310155238
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: BAUER RESIDENTIAL SANTA MARIA 4
FACILITY NUMBER: 425801936
VISIT DATE: 03/21/2022
NARRATIVE
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Email records indicate another tele-appointment on 2/14/22 was missed. The Administrator stated he wrote the appointment down for the wrong day (2/24/22 instead of 2/14/22), even though C1’s Service Coordinator sent a reminder email on 2/3/22 indicating the appointment was scheduled for 2/14/22 at 2:30pm. On 2/15/22, the Service Coordinator said they would reach out to schedule another appointment.

Email records indicate on 2/25/22, a new tele-appointment was scheduled for 3/7/22 at 11:00am. C1’s Service Coordinator asked the Administrator for confirmation that he could attend and provide an alternate phone number he could be reached at. Administrator provided his personal cell phone to the Service Coordinator via email. According to C1’s physician, C1 missed the tele-appointment on 3/7/22. However, the Administrator stated he never received a call from the physician on 3/7/22. Based on the information obtained, this allegation is substantiated.

On the allegation: Staff did not ensure resident completed ordered medical testing timely. C1’s physician indicated blood-work ordered for C1 in August 2021 was not completed timely. Credible witnesses interviewed stated the blood-work is ordered several months in advance, but there is a known issue with facilities receiving the lab orders. The Administrator admitted he did not follow up or put the blood-work date on a calendar, but he usually receives an email a few days after the visit with a blood-work order. Additional emails indicate the blood-work was completed on 3/10/22. Based on the information obtained, this allegation is substantiated. A Technical Violation will be issued related to this allegation.

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

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220310155238
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: BAUER RESIDENTIAL SANTA MARIA 4
FACILITY NUMBER: 425801936
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2022
Section Cited
CCR
85075(b)
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The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs. This requirement was not met as evidenced by:
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Administrator agreed to create a plan to ensure C1 attends scheduled appointments and will send a copy of the plan to CCL by 3/28/22.
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Based on interview and record review, the licensee did not ensure C1 attended scheduled medical tele-appointments, which posed a potential health and safety risk to clients 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3