561703573-2-22-2022-29-AS-DPEA-CQ4S9G-20230320134040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 561703573
Report Date: 02/22/2022
Date Signed: 02/22/2022 03:15:09 PM

Unsubstantiated

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
12/07/2020 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20201207164044

FACILITY NAME:	ELMS RESIDENTIAL CARE		FACILITY NUMBER:	561703573
ADMINISTRATOR:	HIGGINS, FE LILIA 98		FACILITY TYPE:	740
ADDRESS:	67 EAST BARNETT		TELEPHONE:	(805) 643-2176
CITY:	VENTURA	STATE: CA	ZIP CODE:	93001
CAPACITY:	54	CENSUS: 42	DATE:	02/22/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Fe Higgins		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Lack of supervision resulted to resident being assaulted by another resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent visit for the complaint investigation to the above allegation. LPA met with Administrator Fe Higgins and explained the reason for the visit.

During todays visit, LPA conducted physical plant with Administrator and conducted additional interviews with staff. Per report delivered on 09/16/2021 this allegation has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022

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

LIC9099 (FAS) - (06/04)

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