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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 02:47:25 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
12/17/2020 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20201217132859
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:
03:00 PM
ALLEGATION(S):
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Staff did not respond to residents calls for help
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA Diaz conducted the initial investigation, reviewed facility documents and conducted interviews with staff and residents. LPA Diaz interviewed clients on 08/28/21. LPA Diaz interviewed staff on 8/22/21 and 8/24/21. LPA's reviewed R1’s admission agreement, physician’s report, preadmission appraisal, assessment, care plan, and ledgers provided. LPA Olson reviewed records, interviewed 2 staff on 5/16/22, 2 staff and 5 residents on 5/20/22, 2 staff and 6 residents on 6/6/22.

On the allegation: Staff did not respond to residents calls for help. It was alleged that staff arrived late or didn’t respond at all to a resident’s call button. 10/12 residents interviwed stated staff do not respond to calls timely. LPA Olson reviewed call logs from 6/1/20 through 6/4/20. Records show a total of 96 residents used their call button which rang 1-9 times between 6/1/20 starting at 7:30 PM until 6/4/20 8:50 AM.
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-20201217132859
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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32/96 (33%) resident calls were answered in less than 10 minutes, 28/96 (29%) resident calls were answered in 10-20 minutes, 11/96 (11%) resident calls were answered in 21-45 minutes, 25/96 (26%) residents button rang over 9 times and was never responded to. On 5/20/22, the administrator and staff interviewed stated the staff strive to respond to the call within 15 minutes or less. Based on the information obtained, the allegation is deemed Substantiated at this time.

Exit interview, deficiency cited on 9099-D, 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: 2 of 6
Control Number 29-AS-20201217132859
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. This requirement is not met as evidenced by:
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Administrator agreed to create a plan to ensure there is adequate staff to respond to residents timely and will send a copy of the plan to CCL by 6/7/22.
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Based on interview and record review, the licensee did not comply with the above section when they had inadequate staff to respond to call buttons, which posed an immediate 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: 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: 3 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
12/17/2020 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20201217132859

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:
03:00 PM
ALLEGATION(S):
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Staff did not assist resident with hygiene needs
Staff Mismanaged residents medications
Facility overcharged resident for services
Resident is not treated with dignity by staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced complaint visit to issue final findings. LPA Diaz conducted the initial investigation, reviewed facility documents and conducted interviews with staff and residents. LPA Diaz interviewed residents on 08/28/21. LPA Diaz interviewed staff on 8/22/21 and 8/24/21. LPA's reviewed R1’s admission agreement, physician’s report, preadmission appraisal, assessment, care plan, and ledgers provided. LPA Olson interviewed 2 staff on 5/16/22, 2 staff and 5 residents on 5/20/22, 2 staff and 6 residents on 6/6/22 and reviewed records.

On the allegation: Staff did not assist resident with hygiene needs. It was alleged that Resident 1 (R1) was not receiving bathing assistance. 7 out of 7 residents interviewed in 2021 stated that they have no issues receiving services at the facility.

Continued on 9099-A
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: 4 of 6
Control Number 29-AS-20201217132859
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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R1’s physician’s report dated 3/21/2019 indicates R1 can self bathe when R1’s pain is controlled, R1’s pre-admission appraisal indicates standby assistance for showers and R1’s assessment indicates stand by assistance with bathing every other day and was signed by R1 on 4/16/2019. R1’s care plan indicates R1 needed physical assistance with bathing twice weekly the Administrator stated R1 typically would not shower unless staff assisted R1 with it, despite claims R1 had already showered. R1 refused bathing assistance in July and August 2019. Based on the information obtained, the allegations are deemed unsubstantiated at this time.

On the allegation: Staff mismanaged residents medications. It was alleged that Resident 1 (R1) complained on numerous occasions of the inconsistency in receiving medications. LPA Olson reviewed R1’s Medication Administration Record (MAR) from January 2020 through September 2020. July 2020 MAR records indicate on 7/1/20, a 6AM dosage of tramadol-Acetaminophen Tablet 37.5-325 MG was left blank, staff interviewed stated the resident received that medication at 12:10 AM as a PRN, therefore the AM dose was not given, although a code/note should have been attached. The MARs indicated other reasons why medications were not given between January and September 2020, including refusals, orders to hold, medication awaiting delivery, and away from facility. Although one entry on the MAR is missing, there is insufficient evidence to prove that R1’s medication was mismanaged. Due to a lack of evidence, the allegation is unsubstantiated at this time.

On the allegation: Facility overcharged resident for services. It was alleged that Resident 1 (R1) was overcharged for bathing and medication assistance, and was overcharged for a month of care before moving out. 7 out of 7 residents interviewed in 2021 stated that they have no issues receiving services at the facility or and have no problems with refunds. 2 residents stated that they requested the facility to remove specific services that they no longer need, and the facility complied with their requests. R1 was charged for medication assistance in November and December 2019. The Administrator stated when a resident is in the hospital, they stop charges for care but they still charge for medication management because the resident still has medications at the facility even if they are PRN medications. The Administrator stated the staff still count the medications including PRNs everyday, and so therefore still charge for medication assistance unless the resident does not have any medications present in the facility. This is also stated in the admission agreement on page 8 under “Absence from the Community.”
Continued on 9099-C
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: 5 of 6
Control Number 29-AS-20201217132859
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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This is an amended report
R1 and their responsible party both signed the admission agreement on 4/19/2019. R1 was moved from the facility in September 2020 and provided a written 30-day notice on 9/25/2020. R1’s belongings were removed by 9/28/2020. The September 2020 fees were already paid on 9/10/2020, before R1 moved out. The October 2020 fee consisted of a pro-rated room rate only since no care was provided in October. LPA Olson reviewed the records and determined the facility did not charge for anything after the 30-day notice was up. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

On the allegation: Resident is not treated with dignity by staff. It was alleged that Resident 1 (R1) experienced rude behaviors from caregivers like leaving food trays by the door and not placing it by their bedside table, and caregivers would not open the window blinds without being asked. LPA interviewed 12 residents who lived in the facility in 2020. 10/12 residents stated they were treated well and with dignity by staff. Resident 2 (R2) stated staff answered their call buttons eventually but do not assist with the tasks R2 called for, including losing remotes, changing the room temperature, help getting to the bathroom and showers. Staff confirmed they respond to R2’s calls but prioritize other tasks over non-essential tasks R2 asks for. Based on the information obtained, the allegations are deemed unsubstantiated at this time. An advisory note for Technical Assistance is issued to ensure all staff respond appropriately and with dignity to resident’s and their calls.

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

DATE: 06/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6