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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561703599
Report Date: 04/23/2021
Date Signed: 04/26/2021 04:42:16 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
04/16/2021 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20210416133633
FACILITY NAME:LAIGO-ZANDERS HOME FOR THE ELDERLYFACILITY NUMBER:
561703599
ADMINISTRATOR:NORBERTO LAIGOFACILITY TYPE:
740
ADDRESS:3967 EAST DOWNEY COURTTELEPHONE:
(805) 527-3278
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 6DATE:
04/23/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Norberto LaigoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Lack of supervision resulting in resident eloping from facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically/virtually with administrator Norberto Laigo. Allegation was discussed with administrator at aproximately 3:30pm. Administrator explained to LPA that resident #1 left the facility on 4/6/2021 unsupervised. Based on interviews conducted it was revealed that staff allowed resident to go outside unsupervised. Resident left the facility with out staff knowing. Administrator stated that he went to the resident's home and found resident there. Discussion was held regarding the importants of monitoring/supervising residents in the home. At approximately 4:30pm - Resident #1's records reviewed confirmed that resident #1 is not able to leave the facility unassissted.
Based on the above information gathered allegation is deemed saubstantiated at this time.
Pursuant to Title 22 of the CA Code of Regulations, the following deficiency is cited (refer to LIC 809-D):
A telephonic exit interview was conducted with administrator. Copy of this report will be provided via email for signature.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
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-20210416133633
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: LAIGO-ZANDERS HOME FOR THE ELDERLY
FACILITY NUMBER: 561703599
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2021
Section Cited
CCR
87464(d)
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Care and Supervision: A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs...
This requirement has not been met as evidenced by:
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Administrator stated all staff have been in-serviced regarding supervision of residents in care. Administrator shall come up with a plan in writing to ensure that all residents who cannot leave the facility unassisted are regular monitored and not allowed to leave the facility unassisted. Plan and inservice training record shall be submitted by 4/27/2021.
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Based on record review and interview, staff failed to provide appropriate supervision to R1 resulting in elopement, posing an immediate health and safety risk to residents in care.
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Type B
04/30/2021
Section Cited
CCR
87411(a)(1)(D)
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87411(a)(1)(D)Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident.
This requirement was not met as evidenced by:
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Administrator agreed to review reporting requirements and conduct a training with all staff regarding the topic. Proof of staff training shall be provided to CCL by 4/30/2021.
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Based on interviews and file review the Administrator failed to report the elopement of R1 to CCL and other agencies within 7 days which poses a potential health and safety 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC9099 (FAS) - (06/04)
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