425850025-4-26-2023-29-AS-KBUY-CRALXH-20230427090845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 04/26/2023
Date Signed: 04/26/2023 05:08:46 PM

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
02/28/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230228161535

FACILITY NAME:	SANTA MARIA TERRACE		FACILITY NUMBER:	425850025
ADMINISTRATOR:	ENRIQUEZ, SANJUANA		FACILITY TYPE:	740
ADDRESS:	1405 E MAIN ST		TELEPHONE:	(805) 925-8713
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	140	CENSUS:	DATE:	04/26/2023
		UNANNOUNCED	TIME BEGAN:	04:35 PM
MET WITH:	Joanna Enriquez, Administrator		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Facility did not inform authorized representative of change in living arrangement.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA interviewed reporting party on 3/1/23, interviewed Administrator and Care Staff on 3/2/23 and requested relevant documents. LPA met with Administrator and explained the purpose of the visit.

On the allegation: Facility did not inform authorized representative of change in living arrangement. It was alleged that Resident 1 (R1) has dementia yet the facility allowed Resident 2 (R2) to move into R1’s apartment and didn’t inform the authorized representative. All staff interviewed stated that R2 frequently sleeps over and stays in R1’s room all day and night. Some staff state they’ve seen R1 in R2’s room on occasion, usually for coffee in the morning. Administrator stated they did not allow the move, they had no idea until the responsible party called on 2/27/23 and told them R2 moved into R1’s apartment. Staff went to check and saw R2’s closet empty.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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-20230228161535

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: SANTA MARIA TERRACE	FACILITY NUMBER: 425850025
	VISIT DATE: 04/26/2023

NARRATIVE

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Staff notified R2 that they did not have permission to move in and needed to be out the next day. The next day, 2/28/23 R2 moved out. Administrator checked the facility cameras and saw R2 and R1 carrying a cart of things to R1’s room on 2/27/23 at 4:23 pm and then taking a cart back on 2/28/23 at 9:20 am.

LPA interviewed multiple care staff and housekeepers who stated that they had no idea R2 moved in with R1. R2 moved their belongings into R1’s room without notifying staff and when no staff were around in the hallway. As soon as Administrator and staff were aware of the room movement, they acted quickly to move R2 back into their own room. Based on interviews, the allegation: Facility did not inform authorized representative of change in living arrangement is Unsubstantiated.

Exit interview conducted, copy of the report was issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC9099 (FAS) - (06/04)

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