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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802138
Report Date: 06/27/2023
Date Signed: 06/27/2023 06:10:26 PM

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
06/26/2023 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20230626150252
FACILITY NAME:TELECARE AGNES AVENUEFACILITY NUMBER:
425802138
ADMINISTRATOR:CESAR ARGUETAFACILITY TYPE:
772
ADDRESS:116 AGNES AVENUETELEPHONE:
(805) 457-3724
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:10CENSUS: 7DATE:
06/27/2023
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Alex Briceno, AdministratorTIME COMPLETED:
06:20 PM
ALLEGATION(S):
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Staff do not ensure facility has food and water in the quantity necessary to meet needs of residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jenny Olson conducted an unannounced 10-day complaint investigation visit to the facility above. LPA met with Administrator, and explained the purpose of the visit.
On the allegation: Staff do not ensure facility has food in the quantity necessary to meet needs of residents. LPA toured the facility kitchen and food storage areas around 1:50 PM. LPA conducted an inventory of the food in the facility, and observed the supply to be insufficient to meet the requirements of two days perishable and seven days nonperishable for the facility’s 7 clients. Staff interviewed indicated that the food supply has been an ongoing issue for several weeks. Staff stated management has been made aware yet says they have to stay on budget ($1,000/month). Interviews revealed there are often not enough food to feed the clients and staff have been buying food for clients with their own money and not getting reimbursed. Staff stated they brought it up to Regional Director yesterday who immediatly bought food to cover breakfast. Around 2pm today more food was purchased. Based on the information obtained, the allegation is deemed Substantiated at this time.
Exit interview conducted, deficiency cited, report and appeal rights printed and emailed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
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-20230626150252
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: TELECARE AGNES AVENUE
FACILITY NUMBER: 425802138
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2023
Section Cited
CCR
81076(d)(1)
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81076(d)(1) Food Service. Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
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Around 2pm food arrived to the facility. Administrator agreed to send LPA pictures of food shopping receipts for the last 6 weeks by 6/30/2023.
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Based on observation and interviews, the licensee did not comply with the above cited section when they failed to have adequate food supplies, which posed an immediate 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: 06/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3