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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800421
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:17:31 PM

Unsubstantiated


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
10/24/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20241024173840
FACILITY NAME:MILLENIUM CAREFACILITY NUMBER:
565800421
ADMINISTRATOR:MAYA X. DAVIDSZFACILITY TYPE:
740
ADDRESS:1555 HILGARD AVENUETELEPHONE:
(805) 526-4440
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Iris Van Kralingen - AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not treat resident with dignity or respect

Staff prohibit resident from using the facility telephone
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegations listed above. Upon arrival LPA met with staff and explained the reason for the visit. Administrator Iris Van Kralingen arrived shortly after.

At approx. 10:20 a.m. LPA conducted physical plant, interviewed staff, residents, family / responsible parties of residents in care as well as reviewed and obtained copies of pertinent documentation relevant to the investigation.

It was reported that "Staff did not treat resident with dignity or respect" as it was alleged that Staff #1 (S1) has yelled at Resident #1 (R1). LPA conducted interviews with five (5) residents in care, two (2) residents reported that they have never observed any staff member yell or raise their voice at residents. One (1) resident was hospitalized during the visit, and the two (2) remaining residents are unable to communicate effectively.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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-20241024173840
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: MILLENIUM CARE
FACILITY NUMBER: 565800421
VISIT DATE: 10/29/2024
NARRATIVE
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Continued from 9099
Interviews with staff and the Administrator indicated that they have never seen Staff Member #1 (S1) yell at any residents or fail to treat them with dignity and respect. S1 denied ever yelling at any resident in care. Additionally, the LPA interviewed a home health nurse who visits the facility at least twice a week. The nurse stated that they have never observed any staff yell at residents and did not express any immediate or potential concerns regarding staff treatment of residents. Interviews with three (3) families or responsible parties of residents in care revealed that during their multiple visits each week, none of them have observed staff yelling at residents. Each family member or responsible party also indicated they have no concerns regarding staff treating residents with dignity and respect. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not treat resident with dignity or respect" is deemed Unsubstantiated at this time.

It was reported "Staff prohibit resident from using the facility telephone" as it was alleged staff restrict R1 from using the facility telephone.  LPA conducted interviews with five (5) residents in care., two (2)  residents reported that they have always been able to freely use their own phones or the facility phone and have never observed staff restricting any resident from using the phone. One (1) resident was hospitalized at the time of the visit, and the two (2)  remaining residents are unable to communicate effectively. Interviews with staff and the Administrator confirmed that residents are permitted to use their own phones or the facility telephone upon request. The LPA also interviewed a home health nurse who visits the facility at least twice a week. The nurse indicated that they have never observed any staff restricting residents from using the telephone and expressed no immediate or potential concerns regarding phone use.  Additionally, interviews with three (3)  families or responsible parties of residents in care revealed that they each visit the facility multiple times a week and have never observed staff restricting phone use for any resident. Each family member or responsible party also reported no potential or immediate concerns regarding staff restricting phone use for residents. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff prohibit resident from using the facility telephone" is deemed Unsubstantiated at this time.
Exit interview conducted and copy of report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2