425850151-8-9-2024-29-AS-KBUY-D8JUJ5-20240827153655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850151
Report Date: 08/09/2024
Date Signed: 08/09/2024 01:10:15 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
06/26/2024 and conducted by Evaluator Erika Miller

COMPLAINT CONTROL NUMBER: 29-AS-20240626130329

FACILITY NAME:	JIREH SENIOR HOME		FACILITY NUMBER:	425850151
ADMINISTRATOR:	PATRICIA M HERNANDEZ		FACILITY TYPE:	740
ADDRESS:	2102 CALLE MIRASOL		TELEPHONE:	(805) 863-1926
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY:	6	CENSUS: 5	DATE:	08/09/2024
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Patrica Hernandez, Licensee		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Licensee is using a minor to provide care and supervision to residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit on 7/2/24 and 8/9/24 and issued final findings on the allegations above. During the investigation, LPA, Miller, toured the facility and interviewed staff, and residents on July 2, 2024, from 2: 00 p.m. to 4:00 p.m. LPA also obtained and reviewed relevant documents. LPA met with Reyna Morales, administrator and explained the purpose of the visit.

On the allegation: Licensee is using a minor to provide care and supervision to residents in care.
Administrator supervises a minor volunteer (V1) that cooks and plays cards with residents. Administrator is not aware of V1 providing direct care, or supervision of residents. Administrator stated that V1 is not left alone with the residents and has not observed or directed V1 to provide care or supervision of residents. Administrator typically observed V1 during the hours of 8:00 a.m. to 10:00 a.m.
(Continued on 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

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 6

Control Number 29-AS-20240626130329

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JIREH SENIOR HOME	FACILITY NUMBER: 425850151
	VISIT DATE: 08/09/2024

NARRATIVE

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Administrator acknowledged that over a month ago, administrator intervened when V1 was about to assist a resident get up from the dining room table. Administrator advised Licensee that V1 cannot help with any patient care and reminded V1 that they are only permitted to play games and prepare and serve meals.

A staff member stated that V1 monitors 3 to 4 residents sitting at the kitchen table for no more than ten minutes and that it is necessary to have someone in the kitchen.

A resident stated that V1 prepares meals and remains in the kitchen and dinning area while residents eat at the dining room table. The resident stated that V1 is never left alone with residents in the facility. Resident further stated, about V1, “…watches us to make sure we don’t go outside”. Resident was unable to estimate the amount of time V1 spends in the kitchen and monitors residents.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, are being cited on the attached LIC 9099D.

Exit interview conducted, copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
06/26/2024 and conducted by Evaluator Erika Miller

COMPLAINT CONTROL NUMBER: 29-AS-20240626130329

FACILITY NAME:	JIREH SENIOR HOME		FACILITY NUMBER:	425850151
ADMINISTRATOR:	PATRICIA M HERNANDEZ		FACILITY TYPE:	740
ADDRESS:	2102 CALLE MIRASOL		TELEPHONE:	(805) 863-1926
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY:	6	CENSUS: 5	DATE:	08/09/2024
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Patricia Hernandez, Licensee		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Uncleared adult has access to residents in care
Licensee does not ensure that staff are adequately trained
Licensee does not ensure that residents are provided with food that is of quality to meet their needs
Licensee does not ensure that staff are providing adequate care to residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erika Miller (Miller) conducted an unannounced complaint visit on 7/2/24 and 8/9/24 and issued final findings on the allegations above. During the investigation, LPA, Miller, toured the facility and interviewed staff, and residents on July 2, 2024, from 2:00 p.m. to 4:00 p.m. LPA also obtained and reviewed relevant documents. LPA met with Reyna Morales, administrator and explained the purpose of the visit.

On the allegation: Uncleared adult has access to residents in care.
LPA Miller confirmed that all staff members and volunteers were cleared to work in the facility. One volunteer is a minor and is not required to undergo a background clearance.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.
(Continued on 9099 C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 29-AS-20240626130329

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JIREH SENIOR HOME	FACILITY NUMBER: 425850151
	VISIT DATE: 08/09/2024

NARRATIVE

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On the allegation: Licensee does not ensure that staff are adequately trained.
LPA Miller conducted a review of staff records that reflect that all but one staff member has completed various training courses from 2023 and 2024. The administrator sent a letter to staff member advising they must complete training prior to June 5, 2024, or face disciplinary action, including suspension of employment. The staff member called out sick on the days they were scheduled to complete training. The staff member was scheduled for training, but called out sick on both occasions. The staff member last worked on May 25, 2024, and will not be placed on schedule unless they agree to complete online training at home or while at the facility.

There is no evidence to support that staff are not adequately trained. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

On the allegation: Licensee does not ensure that residents are provided with food that is of quality to meet their needs.

LPA Miller observed that refrigerator, freezer, and pantry had ample nutritious foods that included vegetables, frozen and canned foods. LPA also observed leftovers of a meatball soup previously prepared for residents. LPA observed that at the time of visit a resident was eating fresh fruit as a snack. LPA observed resident decline a meal of lasagna and staff provided a different option.

Administrator stated that most residents like salads and typical meals consist of a fish filet, rice, salad and a desert like banana bread, cake, or Jello.

Staff stated that residents are typically served various breakfast foods, French toast, bacon and eggs, fruit, cereal, and toast. For lunch, residents are offered various options like, lasagna, salads, cucumbers, garlic bread, Jello, and or various fruits. Staff stated that they prepare dinner consisting of soups, vegetables, and salads.

(Continued on 9099 C)

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20240626130329

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JIREH SENIOR HOME	FACILITY NUMBER: 425850151
	VISIT DATE: 08/09/2024

NARRATIVE

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2 of 2 residents stated that staff provide good meals that include fruits and vegetables and believe they are served enough food.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

On the allegation: Licensee does not ensure that staff are providing adequate care to residents in care.

LPA observed that residents appeared clean and content. Residents rooms were clean, neat and free of odor.

2 of 2 residents stated that staff quickly respond to their needs and they trust that staff know what they are doing.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, copy of report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20240626130329

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JIREH SENIOR HOME	FACILITY NUMBER: 425850151
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/16/2024 Section Cited CCR 87411(i)(j)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (i) Residents shall not be used as substitutes for required staff ...(j) Volunteers may be utilized,,,,Volunteers shall be supervised. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee agreed to sumbit a statement of understandning that volunteers must be supervised at all times and not left alone with residents in care.
	8 9 10 11 12 13 14	Based on staff and residents intervews, the licensee did not ensure that Volunteers were supervised at all times which poses a potential Health, Safety or Personal Rights risk to residents in care.	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: Erika Miller	TELEPHONE: (805) 450-0283
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024

LIC9099 (FAS) - (06/04)

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