561703573-4-21-2023-29-AS-DPEA-CRB239-20230427170157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 561703573
Report Date: 04/21/2023
Date Signed: 04/21/2023 06:16:25 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
04/05/2023 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20230405151719

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: 41	DATE:	04/21/2023
		UNANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:	Angie Perez Assistant Manager		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Facility staff does not serve nutritious meals.
Staff do not provide resident with basic laundry service

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to the facility at 7:30 a.m. LPA was greeted by Night Supervisor Reynaldo Tabing and the reason for the visit was explained. LPA also met with Interim Administrative Assistant, Karena Higgins, and Assistant Manager, Angie Perez during the visit. LPA contacted facility administrator Fe Higgins who was unable to be present during today’s visit.

On 4/12/2023, LPA toured the facility with Staff Angie Perez between 7:53AM – 8:05AM, after the tour LPA observed breakfast service been provided to the residents in the dining room. A tour of the laundry room was also conducted at 10:30AM. Additionally, LPA conducted a file review and requested copies of pertinent documents at 12:20 p.m. Between 8:12 a.m. – 2:00 p.m. LPA interviewed sixteen (16) random residents and four (4) random staff. Moreover, LPA observed lunch service been provided to the resident at 12:00 p.m.

Report will continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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 7

Control Number 29-AS-20230405151719

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
	VISIT DATE: 04/21/2023

NARRATIVE

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During today's visit LPA observed breakfast being prepared at 7:30 a.m. and breakfast service been provided to the residents in the dining room at 8:00 a.m. Additionally, LPA interviewed four (4) random staff, obtained pertinent documents, and toured the Kitchen and food storage area with night supervisor between 7:40 a.m. -10:15 a.m.

The allegation of ‘Facility staff does not serve nutritious meals’ alleges that for breakfast residents are only being provided pastries and toast and are not being offered fruits and vegetables. LPA interviewed staff and residents during both initial and subsequent visits. During the inspection, on both visits LPA observed the same breakfast meal been served to residents consisting of one (1) fried egg, toast with butter, jam, a small bowl of fruit. Residents also had an option of oatmeal or cold cereal (Rice Crispies, Corn Flakes, or Cheerios,) and a variety of drinks (orange juice, milk, coffee, and iced tea). LPA observed the bowl of fruits to only consist of a few slices of bananas. Interviews with residents and staff revealed that even though residents enjoy breakfast due to the surplus of continental items such as pancakes, bagels, waffles, toast with butter, pastries, and donuts, they are not being provided fresh fruit and vegetables every day. LPA reviewed menus, and it did not have too many options of fresh fruits for breakfast as on certain days only one fruit is being listed. The LPA did not observe sufficient fresh fruit or vegetables in the kitchen to suffice forty-one (41) residents. Based on interviews and observation, there is sufficient evidence to determine that facility residents are not provided vegetables or adequate amounts of fresh fruits. Therefore, the above allegation “Facility staff does not serve nutritious meals” is deemed SUBSTANTIATED at this time.

The allegation of ‘Staff do not provide resident with basic laundry service.’ alleges that the facility does not have enough time to provide laundry services in a timely manner resulting with residents in the same clothing for several days. Resident and staff Interviews revealed that the facility has been experiencing staff retention/scheduling issues which have resulted in issues with residents receiving their laundry on time. Interview conducted with facility administrator revealed that facility is experiencing a shortage of staffing and therefore, it has been difficult to ensure laundry is done timely. Administrator stated that she will ensure the laundry issues get resolved and that staff have been staying longer to make sure laundry gets done. Based on information gathered, the above allegation “Staff do not provide resident with basic laundry service” is deemed SUBSTANTIATED at this time.

Report will continue on LIC9099-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 29-AS-20230405151719

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
	VISIT DATE: 04/21/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	The following deficiencies were observed (See LIC 9099-D.) and cited from the CA Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted and report reviewed with Assistant Manager Angie Perez. A copy of the report and appeal rights were provided

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
04/05/2023 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20230405151719

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: 41	DATE:	04/21/2023
		UNANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:	Angie Perez Assistant Manager		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Staff do not meet resident’s dietary needs.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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 7

Control Number 29-AS-20230405151719

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
	VISIT DATE: 04/21/2023

NARRATIVE

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SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 29-AS-20230405151719

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/28/2023 Section Cited CCR 87555(a)	1 2 3 4 5 6 7	87555 General Food Service Requirements(a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall ..... and served in a safe and healthful manner. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to submit an updated menu and proof of sufficient fresh fruit and vegetable supply by Friday 4/28/23. In addition to communicating to staff what licensing is requesting.
	8 9 10 11 12 13 14	Based on observation and interview, the licensee failed to comply with the section cited above as the facility failed to provide adequate amounts of fresh fruits and vegetables which poses a potential health risk to persons in care.	8 9 10 11 12 13 14
Type B 04/28/2023 Section Cited CCR 87307(a)(3)(F)	1 2 3 4 5 6 7	87307Personal Accommodations and Services (a)(3)(F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to submit proof of adequate housekeeping staff schedule ensuring laundry services are getting done in a timely manner by Friday 4/28/23
	8 9 10 11 12 13 14	Based on interviews, the licensee failed to comply with the section cited above as the facility failed to provide basic laundry service due to staff retention/scheduling issues which poses a potential health risks to persons in care.	8 9 10 11 12 13 14

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC9099 (FAS) - (06/04)

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