561703573-11-5-2021-29-AS-KHEN-C8UTRE-20211117135722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 561703573
Report Date: 11/05/2021
Date Signed: 11/05/2021 02:47:58 PM

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
04/06/2021 and conducted by Evaluator Joann Rosales

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210406094153

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: 44	DATE:	11/05/2021
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Fe Higgins		TIME COMPLETED:	02:47 PM

ALLEGATION(S):

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Facility staff did not provide resident's medical information to resident's health care provider

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) JoAnn Rosales conducted a subsequent complaint investigation to deliver final investigation findings. LPA met with Administrator Fe Higgins.

Concerns were that facility staff did not provide resident #1 (R1)’s medical information (COVID vaccination dates) to residents health care provider. Interview with facility staff and the Administrator on 4/12/21 starting at 11:47 am revealed that during phone calls with R1’s Case Manager on 4/16/21 they were asked if R1 had received their COVID vaccinations and they advised R1’s Case Manager that R1 had received both COVID vaccinations. Interview conducted with R1’s Case Manager on 4/16/21 at 11:09 am revealed that while at a physician’s appointment with R1 on 4/2/21 they called and spoke with the facility Administrator who indicated that R1 did have their COVID vaccines however, they did not have the exact dates available when they called. R1’s Case Manager stated that another staff at the facility knew the vaccination dates and was unavailable at

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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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Control Number 29-AS-20210406094153

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: ELMS RESIDENTIAL CARE	FACILITY NUMBER: 561703573
	VISIT DATE: 11/05/2021

NARRATIVE

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at the time of their call. R1’s Case Manager stated that when they returned to the facility with R1 the facility staff provided them with R1’s COVID vaccination dates. Based on the information obtained during the course of the investigation the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Today's reports and appeal rights were reviewed and emailed to Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC9099 (FAS) - (06/04)

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