565800134-12-22-2021-29-AS-DPEA-C9ZPJ7-20211224102104

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800134
Report Date: 12/22/2021
Date Signed: 12/22/2021 03:17:00 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
09/17/2021 and conducted by Evaluator Martha Guzman-Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20210917121733

FACILITY NAME:	THOUSAND OAKS HOMECARE III		FACILITY NUMBER:	565800134
ADMINISTRATOR:	GILLIANA SHERMAN		FACILITY TYPE:	740
ADDRESS:	143 WEST SIDLEE STREET		TELEPHONE:	(805) 494-8860
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	0	CENSUS: 0	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	02:31 PM
MET WITH:	Gilliana Sherman		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility does not serve residents adequate food in quality and quantity

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted a subsequent telephonic complaint visit to deliver the findings for the above allegation, as the facility underwent a Change of Ownership (CHOW) effective 10/04/2021. The purpose of the telephonic visit is to deliver findings for the above allegation and to conclude an investigation initiated on 09/17/2021. LPA spoke with Administrator, Gilliana Sherman and the reason for the call was explained. Entrance interview conducted.

During the initial 10-day visit, between 1:27 p.m. and 4:12 p.m., LPA Guzman Chavez conducted a physical plant tour, interviewed the Administrator, two facility staff, and two residents. At 2:10 p.m., the LPA conducted a record review and obtained copies of pertinent documents. LPA Guzman Chavez conducted additional interviews with resident family members on 09/27/2021 at 10:26 a.m., on 09/29/2021 at 8:26 a.m., and on 10/14/2021 at 8:53 a.m.

Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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-20210917121733

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: THOUSAND OAKS HOMECARE III	FACILITY NUMBER: 565800134
	VISIT DATE: 12/22/2021

NARRATIVE

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Continued from LIC 9099...

It was alleged that the facility does not serve residents adequate food in quality and quantity. It was further reported that food choices were limited, pasta was served frequently, small portions, spoiled and re-heated food was being served, and overall poor quality of meals.

Information gathered during the course of the investigation revealed that there were no concerns with adequate food in quality and quantity. Interviews with the residents revealed that they get a good amount in food, although sometimes it does lacks salt or seasoning. Interviews with staff revealed that residents are given certain dietary foods per their physician’s orders. Certain residents are on either pureed diets, low sodium, or low carb diets. Interview with the Administrator revealed that staff create a list of groceries which she purchases and delivers to the facility every week. Also, none of the resident’s family members have made any comments to staff or herself regarding the food served to the residents. Interviews with resident family members revealed that they have visited their family members during mealtimes and have seen the meals they get served. They stated, “they do feed them well there”. Furthermore, resident’s family members also mentioned the facility serves good food and added that it looked appetizing and was a good amount for any adult. On 09/24/2021, the LPA observed sufficient food and of good quality present at the facility’s refrigerator, freezer, and facility pantry. The LPA also observed residents during lunch time, one resident was having lentil soup, while another resident was having a peanut butter and jelly sandwich, baked potato chips, and juice. Based on observation and interviews, the allegation that “Facility does not serve residents adequate food in quality and quantity” is deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued. A copy of report provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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