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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561703345
Report Date: 11/29/2022
Date Signed: 11/29/2022 04:59:44 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
05/19/2020 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20200519102236
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:
11/29/2022
UNANNOUNCEDTIME BEGAN:
04:39 PM
MET WITH:N/A closed FacilityTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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Staff handled resident's in a rough manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon issued final findings for this investigation via certified mail, regular mail and email. The facility closed on 6/22/2021.

On the allegation: Staff handled residents in a rough manner. LPA interviewed the reporting party on 5/26/2020 at 9:38am. LPA conducted staff interviews on 6/1/2020 starting at 11:07am and on 6/2/2020 starting at 11:33am.

Staff interviewed stated that Resident 1 (R1) will try to punch staff when they change his brief, so staff may hold their hands, tell R1 they are safe, and talk with R1 to distract R1 while another staff changes the resident. One staff stated when R1 would not allow staff to change them, staff held R1 down by holding R1’s wrists on the bed while another staff held R1’s legs at their ankles, while a third staff changed the brief. Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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-20200519102236
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: 11/29/2022
NARRATIVE
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 Staff stated this happened two or three times. Staff indicated the resident became less resistant to brief changes after a change in medications and that it did not occur after those two or three occasions. Staff stated they did not report these incidents to the Administrator at the time. Another staff verified they observed a staff hold R1’s wrists on the bed, and also thought they recalled staff holding R1’s feet down as well. Based on the information obtained during the investigation, the allegation that staff handled residents in a rough 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).

Reports and appeal rights were mailed/emailed to the former licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20200519102236
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: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/29/2022
Section Cited
CCR
87468.1(a)(1)
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(a)...(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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POC: Facility is closed.
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Based on interviews, the licensee did not comply with the above cited section with staff held down R1’s hands and feet while changing, which posed an immediate personal rights 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: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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
05/19/2020 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20200519102236

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:
11/29/2022
UNANNOUNCEDTIME BEGAN:
04:39 PM
MET WITH:N/A closed FacilityTIME COMPLETED:
05:05 PM
ALLEGATION(S):
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9
Staff not properly trained in transferring resident's resulting in injury
Staff verbally abuse resident's.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon issued final findings for this investigation via certified mail, regular mail and email. The facility closed on 6/22/2021.

On the allegation: Staff were not properly trained in transferring residents resulting in injury. LPA interviewed the reporting party on 5/26/2020 at 9:38am. LPA conducted staff interviews on 6/1/2020 starting at 11:07am and on 6/2/2020 starting at 11:33am. Some staff interviewed stated they received training on transferring residents and on caring for residents with dementia. Staff interviewed stated they felt the other staff were well trained, and that staff always lift with two people or use a hoyer lift. Staff interviewed indicated they know the proper way to turn and lift residents. Other staff interviewed stated they were sure to be “delicate” with residents that were more sensitive or that had existing pain.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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-20200519102236
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: 11/29/2022
NARRATIVE
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 Staff interviewed stated they had not observed any unusual bruising on residents and were unaware of injuries sustained during transfers. One staff interviewed stated they were informed of bruises on Resident 2 (R2)’s back of neck. Staff stated R2 does not need assistance with transfers, and that the resident tends to fall back in their chair when being changed, so staff need to be aware of that. Staff were unaware of the exact cause of bruising on the neck. One staff interviewed stated they hurt their back in September 2019 while lifting a resident out of bed alone. Staff stated they had only received between 3 and 8 hours of shadowing for training. The staff stated that while they received an injury due to an improper transfer, they were unaware of any residents sustaining injuries like bruises due to improper transferring. Another staff stated they injured their back in July 2019 while lifting heavy residents. The staff stated they were not taught how to lift the residents and only received a couple of days of shadowing for 2-8 hours. This staff also corroborated that no residents were injured due to improper transferring. The facility was cited on 1/16/2020 for inadequate staff training and cleared the plan of correction by ensuring staff had sufficient training in February 2020. There was in sufficient evidence gathered to suggest that residents sustained injuries due to improper transfers caused by a lack of training. Therefore, the allegation is deemed unsubstantiated at this time.
On the allegation: Staff verbally abuse residents. LPA interviewed the reporting party on 5/26/2020 at 9:38am. LPA conducted staff interviews on 6/1/2020 starting at 11:07am and on 6/2/2020 starting at 11:33am. Resident responsible parties were interviewed on 9/13/2022 at 1:58pm, and on 9/14/2022 at 8:59am, 12:45pm and 2:58pm. Staff interviewed stated they had never observed Staff 1 (S1) or any other staff verbally abuse the residents. One staff interviewed stated that they did not believe staff verbally abused the residents. However, they recalled an incident where a resident rolled out of bed and fell and hit their face. Another caregiver told the resident they “looked bad” after due to the facial bruising sustained from the fall. Another staff at the facility reprimanded the staff for not being professional with that comment. Resident responsible parties interviewed stated that they were not aware of any verbal abuse or verbal altercations between staff and residents. Responsible parties stated the staff were caring and observed staff to be kind to the residents. Based on the information obtained during the investigation, the allegation that staff verbally abused the residents is unsubstantiated at this time.
Reports and appeal rights were mailed/emailed to the former licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5