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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800706
Report Date: 11/27/2023
Date Signed: 11/27/2023 12:40:38 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
08/28/2023 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20230828153305
FACILITY NAME:SALLY'S RESIDENTIAL CARE HOME, INC.FACILITY NUMBER:
565800706
ADMINISTRATOR:KAYHAN MOJABIFACILITY TYPE:
740
ADDRESS:953 ANDANTE CT.TELEPHONE:
(805) 389-0922
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:6CENSUS: 6DATE:
11/27/2023
UNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Sara Jackson, Facility DesigneeTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff are interfering with resident's facility transfer
Staff did not allow resident out of the facility for a doctor's appointment
Staff did not allow resident to have visits/visitors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit with the purpose of delivering findings for the allegations listed above. LPA arrived at 10:32AM and initially met with facility staff Flordeliza (Flor) Paltep. Licensee Representative Sara Jackson was contacted via telephone and arrived at 10:40AM. Entrance interview conducted.

During an initial complaint visit, conducted on 09/06/2023, LPA interviewed Resident #1 (R1) at 09:19AM, interviewed Licensee Representative at 10:08AM, facility staff at 10:12AM and throughout the visit, toured the facility with Licensee Representative at 10:52AM. LPA reviewed and received copies of documents pertinent to the visit. LPA then reviewed copies of all documents obtained and conducted telephone interviews with other relevant parties. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
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 6
Control Number 29-AS-20230828153305
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: SALLY'S RESIDENTIAL CARE HOME, INC.
FACILITY NUMBER: 565800706
VISIT DATE: 11/27/2023
NARRATIVE
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Allegation: “Staff are interfering with resident's facility transfer:”

LPA interviewed R1, as well as facility staff, and other relevant parties. Prior to receiving the complaint, LPA had received a telephone call from R1, where R1 had just been informed by a healthcare provider that R1’s family member is moving R1 to another facility. R1 called LPA and stated “I don’t want to move. Can they make me move? I don’t want to go.” LPA indicated to R1 that every resident has personal rights, including the right to refuse. During a visit at the facility, LPA provided R1 with a copy of CCLD’s personal rights. During the initial complaint visit, LPA observed R1 and asked R1 to demonstrate making a phone call to LPA. LPA confirmed that R1 has LPA’s business card in their address book and R1 is able to use the facility’s phone to dial LPA’s listed phone number. R1 was also in communication with LTCO and APS with relation to the move and R1 had indicated to both parties they did not wish to move, and it is their choice to remain in this facility. Interview with facility staff confirmed that R1 wishes to remain in this facility and that at no time has any employee from Sally’s Residential attempted to persuade R1 into staying at this facility. Interview with R1 revealed that they are happy in their current residence and wish to remain residing at Sally’s. Facility staff indicated they were informed that R1 would be moving at the end of July. R1’s family member asked that an LTCO representative be present at the facility on the scheduled move out date. LTCO arrived at the facility and remained with R1 for some time on the scheduled move out date, however, no one arrived to transport R1. Therefore, R1 remained in the facility. Based on interview, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “facility staff interfered with resident’s facility transfer” is deemed UNSUBSTANTIATED at this time.

Allegation: “Staff did not allow resident out of the facility for a doctor's appointment:”

LPA conducted interviews with facility staff, R1, as well as other pertinent parties. Additionally, LPA reviewed medical documents for R1. LPA had received a voicemail message from R1 on both 08/21 and 08/22/2023 related to an upcoming medical appointment and concerns regarding the mode of transportation for the scheduled appointment. LPA also received a message from LTCO related to R1’s medical appointment. LPA spoke with R1 over the phone on 08/23/2023, and R1 indicated they would not be going to the medical appointment and R1 had requested that the appointment is cancelled due to R1's concerns with transportation. During that phone conversation and the interview with R1 conducted during the initial complaint visit, R1 indicated to LPA that R1 gets anxious and carsick when traveling in a small personal

Report Continued on LIC 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20230828153305
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: SALLY'S RESIDENTIAL CARE HOME, INC.
FACILITY NUMBER: 565800706
VISIT DATE: 11/27/2023
NARRATIVE
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vehicle. R1 had requested transportation via a larger van or bus, such as the Camarillo Area Transit (CAT) bus, as had been provided previously to transport R1 to medical appointments. R1 also requested that a caregiver accompany them to their medical appointment to tend to R1’s personal care needs while out of the facility. However, R1’s family member scheduled a transportation service to provide transportation and escort to the medical appointment. Transportation was to be provided in a sedan and interview with driver indicated they are contracted to escort the resident to the appointment, but they do not provide services with personal care needs while out of the facility, such as assisting R1 with toileting needs. At R1’s request, facility staff and LTCO both offered to accompany R1 to their scheduled appointment and all offers were refused by R1’s family member. Interview revealed that it was R1’s family member who told facility staff they were not to attend this specific medical appointment with R1, as the driver only was to accompany R1. Interview revealed that the driver had visited the facility on 08/21/2023 to introduce themselves to R1 and to discuss the upcoming appointment. Both driver and R1 indicated that during this meeting, R1 stated they are not going to the appointment as arranged. On the date of the appointment, the driver arrived at the facility and spoke with R1, who again indicated they refuse to leave the facility with the driver to attend the medical appointment. Interviews with all parties revealed that facility staff allowed the driver to enter the facility and speak with R1 themselves and it wasn’t until after R1 refused to leave with the driver that facility staff told the driver they cannot force R1 to leave the facility against R1’s wishes. Police report reviewed indicated that “patient (R1) refused to go with her (driver.)” Additionally, during the course of the investigation, LPA reviewed R1’s medical records and spoke with medical personnel related to R1’s medical visits. Documents and interview confirmed that at R1’s request, facility staff have accompanied R1 to many medical appointments, most recently on 08/03/2023 and 06/09/2023. Interview with R1 revealed that had facility staff or LTCO been allowed to accompany R1 to the appointment on 08/28/2023 and transportation was provided in a larger vehicle, R1 would have gone to the medical appointment. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “staff did not allow resident out of the facility for a doctor’s appointment” is deemed UNSUBSTANTIATED at this time.

Allegation: “Staff did not allow resident to have visits/visitors:”

The complaint alleges that the scheduled driver for R1’s medical appointment was not allowed into the facility. LPA reviewed the facility’s visitor sign in logs, as well as conducted interviews with all relevant parties,

Report Continued LIC 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20230828153305
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: SALLY'S RESIDENTIAL CARE HOME, INC.
FACILITY NUMBER: 565800706
VISIT DATE: 11/27/2023
NARRATIVE
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including the driver. Sign in logs reflect R1 had visitors on the following dates: 08/21/2023 (driver), 08/25/2023, 08/26/2023 (2 visitors), 08/28/2023 (driver and 2 additional visitors), and 08/29/2023 (2 visitors). Interviews revealed that all visitors entered the premises, signed in on the visitor log inside the facility’s entryway, and conducted visits inside the facility. Interview with driver as well as facility staff revealed that R1’s driver sat on the couch in the living room of the facility after signing into the facility. R1 was outside on the facility patio upon the driver’s arrival, so driver did go outside to speak with R1. Visitor logs indicate the driver signed in at 09:55AM. R1 refused to leave the facility with the driver, but the driver did remain on premises at the facility. Police report indicates that driver was escorted off the facility premises at 11:25AM. Parties interviewed indicate that the driver was inside the facility as well as on the back patio during the time they were at the facility. Visitor log reviewed indicates that R1 had 9 visitors over the course of an 8-day period. Based on interview and record review, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation that “Staff did not allow resident to have visits/visitors” is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. No citations issued. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
08/28/2023 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20230828153305

FACILITY NAME:SALLY'S RESIDENTIAL CARE HOME, INC.FACILITY NUMBER:
565800706
ADMINISTRATOR:KAYHAN MOJABIFACILITY TYPE:
740
ADDRESS:953 ANDANTE CT.TELEPHONE:
(805) 389-0922
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:6CENSUS: 6DATE:
11/27/2023
UNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Sara Jackson, Facility DesigneeTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not safeguard resident's money
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint visit with the purpose of delivering findings for the allegation listed above. LPA arrived at 10:32AM and initially met with facility staff Flordeliza (Flor) Paltep. Licensee Representative Sara Jackson was contacted via telephone and arrived at 10:40AM. Entrance interview conducted.

During an initial complaint visit, conducted on 09/06/2023, LPA interviewed Resident #1 (R1) at 09:19AM, interviewed Licensee Representative at 10:08AM, facility staff at 10:12AM and throughout the visit, toured the facility with Licensee Representative at 10:52AM. LPA reviewed and received copies of documents pertinent to the visit. LPA then reviewed copies of all documents obtained and conducted telephone interviews with other relevant parties. The following was then determined:

Report Continued on LIC 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20230828153305
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: SALLY'S RESIDENTIAL CARE HOME, INC.
FACILITY NUMBER: 565800706
VISIT DATE: 11/27/2023
NARRATIVE
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It was alleged that the facility did not safeguard R1’s money, as there was money missing and R1 does not know where the money goes. Record review revealed that R1 is not capable of handling their own finances. Interviews revealed that R1 does not handle their own finances. Instead, R1 has a Power of Attorney (POA) for finances and this person pays all of R1’s expenses, including R1’s contracted rate at the facility. R1 does not have access to their money nor their financial records. Staff interviewed indicated that they do not handle cash resources for any of the residents in their facility, including R1. Based off the information obtained, the allegation is deemed UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis.

No citations issued. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6