425850033-1-27-2022-29-AS-KBUY-CBJ3A7-20220210170417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850033
Report Date: 01/27/2022
Date Signed: 01/27/2022 06:26:56 PM

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
10/12/2021 and conducted by Evaluator Arien Diaz

COMPLAINT CONTROL NUMBER: 29-AS-20211012122707

FACILITY NAME:	AAA KINDNESS CARE II		FACILITY NUMBER:	425850033
ADMINISTRATOR:	PETTIFORD, SHAYNA		FACILITY TYPE:	740
ADDRESS:	3811 DOMINION RD		TELEPHONE:	(805) 937-6444
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	32	CENSUS:	DATE:	01/27/2022
		UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Shayna Pettiford		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff allowed resident to leave the facility with an unauthorized person

INVESTIGATION FINDINGS:

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LPA Diaz reviewed facility documents and conducted interviews with staff and residents. LPA interviewed staff on 01/05/2022 at 5:42pm and 6:21pm and on 01/06/2022 at 5:17pm and 6:30pm. LPA interviewed staff on 01/09/22 at 11:50am, 12:14pm, 1:02pm, and 5:03pm. LPA interviewed staff on 01/10/22 at 11:09am. LPA interviewed residents on 01/10/22 between 1:00pm and 2:30pm.

On the allegation: Staff allowed resident to leave the facility with an unauthorized person. 8 out of 8 staff stated they understand what a mandated reporter is and would report any abuse to their administrator or the Licensing agency. All staff stated the procedures for when residents leave the facility, and that the resident’s responsible party calls the facility and discusses the details about the residents outing or medical appointment in advance. If residents need to take medication during their outing, the responsible party must sign the medication release form.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

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 3

Control Number 29-AS-20211012122707

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: AAA KINDNESS CARE II	FACILITY NUMBER: 425850033
	VISIT DATE: 01/27/2022

NARRATIVE

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The residents also have chaperones when they leave the facility, and chaperones can be the power of attorney (POA), a family member, or caregivers from the facility. Third party transports are also used to pick up and drive residents to their appointments. However, drivers must have a chaperone to advocate for the resident. The resident appointment is indicated on three calendars located in three different areas in the facility. All staff members can review the calendars, thus are aware of resident appointments.

The staff also utilize a phone application to organize and illustrate resident appointments. According to the administrator, resident 1, (R1’s) daughter emailed the administrator about R1’s doctor’s appointment at 12pm. Then the administrator received a follow up text message from R1’s daughter stating that the appointment had been changed to 10/05/2021 at 1:45pm. The text message also indicated that R1s second daughter will be joining R1 and the third-party driver. According to the staff members at the facility on 10/5/21, the driver arrived early at the facility around 11:45am. The driver was screened, checked in and asked to wait on the patio for R1. Staff member 1 (S1) stated they were unaware of the doctor’s apportionment on 10/5/21 but was notified that the driver was waiting on the patio for R1. S1 brought R1 to the driver and then S1 went back inside the facility. The second daughter arrived late at the facility around 12:15pm and was looking for R1. The administrator immediately called the driver and had them return to the facility. The staff stated there was a miscommunication between S1 and the driver and as a result the driver took the resident without a chaperone. According to the administrator, the facility would never let R1 attend appointments alone. R1 is nonverbal and has dementia. The Administrator provided the LPA with a copy R1s physician report. LPA reviewed R1s physician report and it indicates that R1 is unable to leave facility unassisted. All verbal residents stated that they are accompanied by someone during outings. Based on the interviews and records reviewed, On the allegation: Staff allowed resident to leave the facility with an unauthorized person is deemed substantiated at this time.

Exit interview, report given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20211012122707

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: AAA KINDNESS CARE II	FACILITY NUMBER: 425850033
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/28/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following...: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.	1 2 3 4 5 6 7	Administrator will ensure that no resident will be released to transport and only to the resident’s responsible party. Administrator will retrain staff regarding outings and apportionments.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 left the facility with an unqualified person to meet the resident needs.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022

LIC9099 (FAS) - (06/04)

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