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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 561703599
Report Date: 05/18/2022
Date Signed: 05/20/2022 09:54:20 AM

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
05/18/2022 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20220518152544
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:
05/18/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Norberto LaigoTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility did not provide resident's records to resident's authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) initiated a complaint visit regarding above allegation.

Information was received that on 12/22/2021, a formal letter requesting former resident's records was made by reporting party. No response was made by Licensee/Administrator. The facility never responded to the records request. Facility licensee/administrator failed to respond to request. Mr. Laigo stated that he was out of the country when the letter was received and it was not opened until he returned. At that time the deadline had expired and Mr. Lagio stated that he did not produce any records or contact the requesting party.

Based on the information gathered above, allegation is deemed substantiated at this time.
Pursuant to Title 22 of the CA Code of Regulations, the following deficiency is cited (refer to LIC 809-D):
Exit interview conducted and copy of report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
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 2
Control Number 29-AS-20220518152544
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: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2022
Section Cited
CCR
87506(c)(1)
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(c) All information and records obtained from or regarding residents shall be confidential. (1)The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential
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The licensee/administrator has agreed to the following: Respond to the requesting party. Submit proof of communication and date indicating availability of records or copies of the records to R1's representative requesting the records.
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information only upon the resident's written consent or that of his designated representative. This requirement has not been met as evidenced by: Based on interview with Administrator: R1's facility records were not produced as requested, which poses a potential personal rights
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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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2022
LIC9099 (FAS) - (06/04)
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