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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800182
Report Date: 05/23/2023
Date Signed: 05/23/2023 04:24:05 PM


Document Has Been Signed on 05/23/2023 04:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:ST. PAUL'S R.C.F.E.FACILITY NUMBER:
565800182
ADMINISTRATOR:MALARI MARILOUFACILITY TYPE:
740
ADDRESS:2292 GODDARD AVETELEPHONE:
(805) 581-9457
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:5CENSUS: 4DATE:
05/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:52 PM
MET WITH:Marilou MalariTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20230504142222). The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation.

During the complaint investigation of complaint #29-AS-2023050414222), the following deficiency was observed: On 05/23/2023, while LPA waited for the Administrator in the living room to arrive at the facility, Staff #1 (S1) was observed speaking to Staff #2 (S2) as to why Licensing was visiting the facility. At 3:00 p.m., S1 was observed speaking S2 using inappropriate language and discussing confidential information in front of residents in care.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).



Exit Interview. Citation issued. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/23/2023 04:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ST. PAUL'S R.C.F.E.
FACILITY NUMBER: 565800182

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2023
Section Cited
CCR
87468.1

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Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff.... (3) To be free from punishment, humiliation,intimidation, abuse...This requirement was not met as evidenced by:
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The Administrator has agreed to have an in-house training with all staff on Regulation 87468.1 Personal Rights of Residents in all Facilities and submit to CCL by 05/25/2023.
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Based on LPA observation, the licensee did not comply with the section cited above as S1 and S2 were observed using inappropriate language and discussing confidential information in front of residents in care, which poses an immediate personal rights 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: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
LIC809 (FAS) - (06/04)
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