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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561703345
Report Date: 10/12/2022
Date Signed: 10/21/2022 03:19:32 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
07/07/2020 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200707133928
FACILITY NAME:TREACY VILLAFACILITY NUMBER:
561703345
ADMINISTRATOR:COLLEEN CONBOYFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA RDTELEPHONE:
(805) 644-1292
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:0CENSUS: 0DATE:
10/12/2022
UNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Patrick TreacyTIME COMPLETED:
11:31 AM
ALLEGATION(S):
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Facility staff failed to treat resident with dignity
Facility staff did not ensure that resident received medical attention in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a telephone visit with Licensee Patrick Treacy to deliver investigation findings as the facility was closed effective 6/22/21.

Concerns were that the facility staff failed to treat resident #1 (R1) with dignity as R1 was admitted to the facility without any shoes and the shoes that were sent by R1’s family member were extremely tight and caused pain. On 7/10/20 starting at 1:57 pm LPA Kristin Heffernan conducted an interview with the Director. On 9/13/22 starting at 1:58 pm LPA Rosales conducted an interview with a resident family member, staff and resident family members on 9/14/22 starting at 8:59 am, and residents on 9/15/22 starting at 11:37 am. Interviews revealed that R1 was admitted to the facility with no shoes only hospital socks. Interviews with resident’s family members revealed that the facility would constantly lose the residents slippers as the resident would be wearing someone else’s slippers and they were always having to buy the resident new slippers.
Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
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 5
Control Number 29-AS-20200707133928
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: TREACY VILLA
FACILITY NUMBER: 561703345
VISIT DATE: 10/12/2022
NARRATIVE
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A review of R1’s records on 7/25/22 starting at 2:19 pm revealed that R1 was admitted to the facility on 5/31/20 with no shoes and only a change of clothes. R1’s family member was notified that R1 would need clothes and shoes. 6/1/20 R1’s family member responded that they would be in on 6/3/20 and did not show so the facility provided R1 with loaner shoes and clothes. R1’s chart notes dated 6/2/20 am shift indicated that R1 needs shoes and sweater. Based on the information obtained, the allegation that facility staff failed to treat resident with dignity is Substantiated at this time.

Concerns were that facility staff did not ensure that resident #1 (R1) received medical attention in a timely manner as R1 should have been seen by a Podiatrist due to R1 being diabetic.

On 7/10/20 starting at 1:57 pm LPA Kristin Heffernan conducted an interview with the Director. On 9/13/22 starting at 1:58 pm LPA Rosales conducted an interview with a resident family member, staff and resident family members on 9/14/22 starting at 8:59 am, and residents on 9/15/22 starting at 11:37 am. Interview with the Director revealed that the facility had a Podiatrist go to the facility once a month and was scheduled to be at the facility on 7/3/20 but rescheduled to go to the facility on the third week of July 2020.

LPA Heffernan received a letter from the Director on 7/13/2020 at 11:22 am which indicates that the Podiatrist had been out of the facility since May 25th and typically goes to the facility once a month and skipped the month of June. Was due to go to the facility in the beginning of July but moved their date to the third week of the month. R1 was on their list to be seen and has been on the list since week 1 of their residency. R1 is diabetic and it is their protocol to have any diabetic resident feet tended to by a Podiatrist and not by staff.

Based on the information obtained, the allegation that facility staff did not ensure that resident received medical attention in a timely manner is Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):



Exit interview conducted. Today's reports and appeals rights were reviewed and mailed certified mail to the Licensee.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20200707133928
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: TREACY VILLA
FACILITY NUMBER: 561703345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2022
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care. (a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not met as evidenced by:
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Facility was closed effective 6/22/21
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Based on interviews and record review, the licensee did not comply with the section cited above as they did not arrange timely medical care for R1 which posed a potential health risk to persons in care.
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Type B
10/12/2022
Section Cited
HSC
1569.269(a)(1)
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1569.269 Enumerated rights; severability (a)(1) Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement is not met as evidenced by:
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Facility was closed effective 6/22/21
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Based on interviews and record review, the licensee did not comply with the section cited above as R1 was not provided shoes in a timely manner which posed a potential personal rights risk to persons 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
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
07/07/2020 and conducted by Evaluator Joann Rosales
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20200707133928

FACILITY NAME:TREACY VILLAFACILITY NUMBER:
561703345
ADMINISTRATOR:COLLEEN CONBOYFACILITY TYPE:
740
ADDRESS:3482 LOMA VISTA RDTELEPHONE:
(805) 644-1292
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:0CENSUS: 0DATE:
10/12/2022
UNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Patrick TreacyTIME COMPLETED:
11:31 AM
ALLEGATION(S):
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Facility staff are financially abusing resident
Facility staff engaged in a verbal altercation with resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a telephone visit with Licensee Patrick Treacy to deliver investigation findings as the facility was closed effective 6/22/21.

Concerns were that facility staff are financially abusing resident #1 (R1)'s $1800.00 cash and credit cards were taken from R1 at admission to the facility. On 7/10/20 starting at 1:57 pm LPA Kristin Heffernan conducted an interview with the Director. On 9/13/22 starting at 1:58 pm LPA Rosales conducted an interview with a resident family member, staff and resident family members on 9/14/22 starting at 8:59 am, and residents on 9/15/22 starting at 11:37 am. Interviews revealed that when R1 was admitted to the facility and they were offered a lock box for their wallet which R1 refused. R1’s wallet was observed by staff on their nightstand and was told to be careful not to leave their wallet out. Interviews with residents and their family members revealed that the facility does not handle their finances.

Continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
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 5
Control Number 29-AS-20200707133928
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: TREACY VILLA
FACILITY NUMBER: 561703345
VISIT DATE: 10/12/2022
NARRATIVE
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LPA Heffernan received an email from the facility on 7/13/2020 at 11:25 am with staff #1 (S1) and S2’s signed statements which indicates that upon admission S1 observed R1’s wallet in a box of R1’s things and R1 was asked if they could keep it secured but R1 refused. S1 noticed R1 had cash in their wallet which R1 allowed staff to count. S1 asked S2 to act as witness. R1 had $130.00 in 20, 10, and 5 dollar bills. S1 insisted to R1 to allow them to put R1’s money under lock and key but R1 refused and said that they would put it in a safe place. S2 stated that R1 allowed S1 to take inventory and S1 proceeded to count R1’s money while S2 watched. The total amount came out to about 130 dollars.

Based on the information obtained, the allegation that facility staff are financially abusing resident is unsubstantiated at this time.

Concerns were that facility staff engaged in a verbal altercation with resident #1 (R1) on 7/3/20 on the issue of privacy.

On 7/10/20 starting at 1:57 pm LPA Heffernan conducted an interview with the Director. On 9/13/22 starting at 1:58 pm LPA Rosales conducted an interview with a resident family member, staff and resident family members on 9/14/22 starting at 8:59 am, and residents on 9/15/22 starting at 11:37 am. Interviews with staff revealed that they are not aware of staff engaging in a verbal altercation with R1 on 7/3/20. Interviews with residents revealed that they have not engaged in a verbal altercation with staff. Interviews with residents family members revealed that the are not aware of any staff engaging in a verbal altercation with any residents.

Based on the information obtained, the allegation that facility staff engaged in a verbal altercation with resident is unsubstantiated at this time.

Exit interview conducted. Today's reports and appeals rights were reviewed and mailed certified mail to the Licensee.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5