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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 02/02/2024
Date Signed: 02/02/2024 04:32:17 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
11/17/2023 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20231117112744
FACILITY NAME:SANTA MARIA TERRACEFACILITY NUMBER:
425850025
ADMINISTRATOR:ENRIQUEZ, SANJUANAFACILITY TYPE:
740
ADDRESS:1405 E MAIN STTELEPHONE:
(805) 925-8713
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:140CENSUS: 95DATE:
02/02/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Vanessa Vazquez, Wellness CoordinatorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not meet resident’s hygiene needs
Resident was charged for services not rendered
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA's) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA interviewed reporting party on 11/22/23 and 2/2/24, interviewed Staff and residents on 11/27/23 and requested relevant documents, interviewed Administrator on 12/15/23 and 2/2/24, and staff and residents on 12/15/23 and 2/2/24. LPA met with Administrator and Wellness Director over the phone and explained the purpose of the visit.

On the allegations: Staff did not meet resident’s hygiene needs and Resident was charged for services not rendered. It was alleged Resident 1 (R1) is paying for 2 showers a week but sometimes doesn’t get their shower and the facility refuses to refund R1. Interviews revealed R1 has a shower log to track the showers R1 receives. It was alleged that on 10/31/23 a staff member called off so R1 was unable to get their shower. Interviews with staff confirmed if there are any call offs Residents don’t receive their shower and the next shift will “try” to complete it. If a resident refuses a shower the policy is to inform the Medtech, the Medtech attempts to shower the resident and if they refuse again they are to inform the Wellness Director.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
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 5
Control Number 29-AS-20231117112744
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: 02/02/2024
NARRATIVE
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Wellness Director stated the shower is then put on the next shift to try to complete the shower. LPA interviewed the Medtech to ask how often showers are refused. Medtech stated there are around 2-3 refusals a week. Medtech stated a resident refused a shower on 11/27/23 (day of interview), they attempted to give the shower and it was refused again, and they were going to inform the Wellness Director. LPA asked if they inform the Medtech coming on the following shift that it was missed and Medtech said no, it’s the caregivers responsibility. LPA interviewed the resident who refused the shower and interviews revealed they didn’t in fact refuse, they just said they weren’t allowed to get their feet wet. LPA asked resident if they gave the caregivers a suggestion how to shower them without getting their feet wet and they said no, that’s the staff’s job to figure out. Resident stated this happens a lot and they don’t receive showers due to this. LPA interviewed Wellness Director who stated they are going to hold an in-service to address showers and better train staff on questions to ask and ways to overcome obstacles of missed showers. LPA observed staff to not have a clear system or way to know if residents missed their shower and could easily forget to tell the next shift. LPA reviewed October and November shower log for R1 which states “resident not available” on 10/24/23 and 10/27/23 and indicates a shower was not given to resident on 10/31/23.

On 1/24/24 Wellness Director stated they implemented a new shower sheet that will be used to make up missed shower schedules. On 12/15/23 Interview with Administrator revealed they are only aware of one missed shower on 10/31/23 and offered to refund the missed shower but the family wanted more refunded. R1 implemented their own system where caregivers sign off when showers are due and then when they are given. LPA observed 9/19/23 say "unable to have shower because someone took all of my towels out of the bathroom". 10/17/23 says "no shower" and 10/31/23 "Unable to have shower, only 1 caretaker." On 2/2/24 interviews revealed the facility issued a refund for the three missed showers on the February 2024 bill. Based on the information obtained, the allegations Staff did not meet resident’s hygiene needs and Resident was charged for services not rendered are deemed Substantiated.

Exit interview conducted, copy of report and appeal rights issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20231117112744
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2024
Section Cited
CCR
87464(f)(4)
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87464 Basic Services (f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... This requirement was not
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Facility implemented a new shower log to better track missed showers. POC is was cleared at the time of the visit.
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met as evidenced by: Based on interviews and record review, the licensee did not comply in the section sited above when staff did not properly assist resident with showers or have a system to make up missed showers which posed a potential health and safety risk to residents in care.
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Type B
02/09/2024
Section Cited
CCR
87507(c)
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87507 Admission Agreement (C) Any fee that is charged prior to or after admission, shall be clearly specified.

This requirement was not met as evidenced by:
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Facility issued a refund. POC cleared during the visit.
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Based on interviews, the licensee did not comply in the section sited above when staff did took 4 months to agree on a refunded shower amount, which posed a potential health and safety 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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/17/2023 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20231117112744

FACILITY NAME:SANTA MARIA TERRACEFACILITY NUMBER:
425850025
ADMINISTRATOR:ENRIQUEZ, SANJUANAFACILITY TYPE:
740
ADDRESS:1405 E MAIN STTELEPHONE:
(805) 925-8713
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:140CENSUS: 95DATE:
02/02/2024
UNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Vanessa Vazquez, Wellness CoordinatorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not adhere to admission agreement
INVESTIGATION FINDINGS:
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3
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5
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10
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12
13
Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA interviewed reporting party on 11/22/23 and 2/2/24, interviewed Staff and residents on 11/27/23 and requested relevant documents, interviewed Administrator on 12/15/23 and 2/2/24, and staff on 12/15/23. and 2/2/24 LPA met with Administrator and Wellness Director over the phone and explained the purpose of the visit.

On the allegation: Staff did not adhere to admission agreement. It was alleged that the cable is not reliable and certain channels don’t work. It was also alleged that the Maintenance Director and Administrator “refused” to call the cable company and fix it. LPA interviewed staff and residents. Interview with Maintenance Director revealed there are 3 channels that need to be reset daily. LPA observed the cable room and staff stated every morning they go and check that every channel is working and if it isn’t they reset it. Maintenance Director stated they called the cable company on 11/22/23 and 11/27/21 and they walked them through a new way to reset the box. Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20231117112744
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: 02/02/2024
NARRATIVE
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Director stated if this reset doesn’t work they will send a technician to come and fix it. On 12/15/23 Administrator stated the cable company came on and fixed both boxes. LPA interviewed Maintenance Director on 2/2/24 that stated since the cable company came out the channels are working better but R1's TV is the problem and skips channels but they are not missing. LPA interviewed R1 who stated the TV gets fixed for a few days then goes back to not working. LPA reviewed the facility’s Admission Agreement which indicates cable services are provided. The Admission Agreement does not delineate the specific channels that will be included/ available in the cable package. Based on the information obtained, the allegation is deemed Unsubstantiated.

Exit interview conducted, copy of report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5