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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850025
Report Date: 06/06/2022
Date Signed: 06/06/2022 04:09:02 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
03/28/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220328112002
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: 94DATE:
06/06/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Vanessa Vazquez, Wellness CordinatorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff not following COVID-19 protocols
Staff does not respond timely to resident calls for assistance
Facility does not have adequate staff
Resident bathroom has a water leak
Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA interviewed residents on 04/5/2022 and 5/20/2022, and 6/6/22. LPA interviewed staff on 04/5/2022, 5/16/2022, 5/20/2022, and 6/6/22. LPA reviewed call button longs, security footage, guest sign-in logs, maintenance and housekeeping room checklist, and pictures of R1’s apartment upon move in.

On the allegation: Staff not following COVID-19 protocols. It was alleged that visitors were not required to wear masks and staff checked guest’s temperature and signed the guest in, but didn’t inquire about vaccination status as required by the guidance at the time of the complaint. Allegedly one guest was unvaccinated and allowed to walk around the facility without a mask and without providing a negative COVID test 3/19/22-3/24/22. On 5/16/22 LPA Olson attempted to view surveillance footage but the system only saves 35 days of footage. LPA did view a sample of 4 hours of footage from 5/7/22 and 4 hours of footage from 5/8/22.
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: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
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 6
Control Number 29-AS-20220328112002
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: 06/06/2022
NARRATIVE
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LPA observed guests arriving with masks on and temperatures being taken. Guests were at the front desk for an average of 30-60 seconds. LPA did not observe any guests take out their phone or wallet to show proof of vaccination or a negative COVID-19 test. LPA observed one child around age 7 or 8 arrive and no paperwork was shown or COVID-19 test administered. LPA viewed visitor logs from 3/19/22-3/24/22 and 5/6/22-5/8/22. Logs did not specify if the individual was vaccinated and showed proof, provided a negative COVID-19 test, or was tested at the facility. PIN 21-40-ASC dating 8/27/21 states that licensees must obtain and track documentation of vaccination or COVID-19 diagnostic test of visitors in order to visit indoors. Verification and record keeping shall take effect on 9/9/21 in accordance with the State Public Health Officer Order. The PIN states “Facilities must have a plan in place for tracking verified visitor vaccination status or documentation of a negative COVID-19 test. Documentation of the verification must be kept on file at the facility and made available upon request to CDSS, or to the local health jurisdiction for purposes of case investigation. Visitors for whom vaccine status is unknown or documentation is not provided, must be considered unvaccinated or incompletely vaccinated.” PIN 22-07-ASC updated 2/7/22 adds that unvaccinated visitors who visit consecutively are required to show a proof of a negative test every third day. Based on the information obtained, the allegation is deemed Substantiated at this time. A Technical Violation Notice Issued. Administrator agreed to redo the sign in sheet and track this data per PIN 21-40-ASC and PIN 22-07-ASC.

On the allegation: Staff does not respond timely to resident calls for assistance. It was alleged that Resident 1 (R1) and their family pressed the pendant for help but no one came in a timely manner. LPA Olson reviewed call logs from 3/22/22-3/25/22. Records indicated R1 made a total of 7 calls. Pages go out to staff for around 5 minutes then automatically send a page out again up to 9 more times until the call is answered. Staff responded under 15 minutes to R1's call 3/7 times. Staff responded 15 minutes or longer 4/7 times, with one call not being responded to all. Records indicate on 3/22/22 at 5:40 PM R1's penant rang 9 times, and states “response required but not received as of 6:25p This alert was never responded to.” On 5/20/22, the administrator and staff interviewed stated the staff strive to respond to calls within 15 minutes or less. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Facility does not have adequate staff. It was alleged that a resident was found wandering the halls and it took time to find a staff to respond. It was alleged that Staff 1 (S1) told R1’s family member that she was working alone that day and had no help.
Continued on 9099-C (2)
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220328112002
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: 06/06/2022
NARRATIVE
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LPA Olson interviewed staff who stated that usually there are 2 staff covering all residents. 4/5 care staff interviewed stated 2 staff was not enough to assist all residents. Staff stated residents with dementia require more attention and that there should be more staff to assist residents because there is a lot of work to do. In March 2022 the facility had 29/91 residents with dementia, 55/91 cannot leave the facility unassisted, 6/91 are on hospice, 12/91 Wander, and currently 1/94 residents need two person assistance (temporarily from 4/20/22- present), 10/94 need transfer assistance, 5/94 are bedridden, 43/94 are non-ambulatory, 16/94 are incontinent, and 11/94 require restroom assistance. 10/14 residents stated that there is not enough staff to assist residents and staff take a long time to respond when they need assistance. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Resident bathroom has a water leak. It was alleged that R1’s bathroom had a water leak and the ceiling had water pouring down and staff responded, “this happens all the time”. LPA Olson interviewed staff and residents that confirmed this happens when an upstairs resident’s toilet overflows or if the resident forgot to place their shower curtain the correct way and the water leaks down to the apartment below. Administrator stated “it is an old building, so it happens”. Facility Maintenance Director confirmed the water leaks through to the apartment below through the toilet if it is not sealed. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Facility is in disrepair. It was alleged that R1’s carpet tiles were dirty; the baseboards, shower head, facial tissue cover and fridge were covered with mold and hair; the toilet had a yellow ring and crusted urine and mold in the toilet seat bolts. LPA observed pictures from the reporting party and observed a yellow ring around the toilet as well as stains on the carpet and inside the fridge. LPA requested room checklist logs from the last 5 move-ins which show what was done prior to residents moving in. Facility could only produce 2/5 logs and calendar reminders/notes from housekeeping for the other 3 rooms. Three staff interviewed stated that all 5 rooms were cleaned and checked by sales, maintenance and housekeeping. One staff stated that they could have done better and the other two stated that management was informed of the condition of R1’s toilet, fridge, and floor prior to R1 moving in. Interviews revealed the toilet and fridge was replaced after R1 moved in. Based on the information obtained, the allegation is deemed Substantiated at this time.

Exit interview, deficiencies cited on 9099-D, Technical Violation issued, report emailed, appeal rights emailed.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20220328112002
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: 06/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/07/2022
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements- Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
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his requirement was not met as evidenced by:
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Administrator agreed to create a plan to ensure there is adequate staff to meet residents needs and to respond to call buttons timely and will send a copy of the plan to CCL by 6/7/22.
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Based on interviews, and documentation the licensee did not ensure there was sufficient staff to meet resident needs which posed an immediate health and safety risk to clients in care.
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Type A
06/07/2022
Section Cited
CCR
87303(e)
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87303(e) Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained.
This requirement was not met as evidenced by:
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Administrator agreed to create a plan to ensure all facility toilets are properly sealed and will send a copy of the plan to CCL by 6/7/22.
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Based on interviews and observation, the licensee did not ensure toilets and bathrooms were properly sealed, allowing water to leak to the apartment bellow, 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20220328112002
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: 06/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
CCR
87303(e)(6)
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87303(e)(6) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement was not met as evidenced by:
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Administrator agreed to create a new plan to ensure rooms are clean and ready to move into prior to admission and will send a copy of the plan to CCL by 6/10/22.
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Based on interviews and observation the licensee did not ensure R1’s room was clean and sanitary upon move in 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
03/28/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220328112002

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: 94DATE:
06/06/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Vanessa Vazquez, Wellness CordinatorTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Electrical conduit is accessible to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA interviewed residents on 04/5/2022, 5/20/2022 and 6/6/22. LPA interviewed staff on 04/5/2022, 5/16/2022, 5/20/2022, and 6/6/22. LPA reviewed call button longs, security footage, guest sign-in logs, maintenance and housekeeping room checklist, and pictures of R1’s apartment upon move in.

On the allegation: Electrical conduit is accessible to residents. It was alleged that R1’s closet had an electrical conduit accessible to residents. LPA observed the closet and only saw a cable that looked to be safe with no exposed wires. Administrator interview revealed that the fire department came to the facility on 4/16/22 to inspect it and it was deemed safe. Based on the information obtained, the allegations are deemed unsubstantiated at this time.

Exit interview conducted, report emailed to Administrator.
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: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6