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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800711
Report Date: 10/18/2021
Date Signed: 10/18/2021 01:40:03 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 Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210917132803
FACILITY NAME:THOUSAND OAKS HOME CARE IVFACILITY NUMBER:
565800711
ADMINISTRATOR:JOVY SARREALFACILITY TYPE:
740
ADDRESS:254 E. SIDLEE ST.TELEPHONE:
(805) 494-8860
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:0CENSUS: 0DATE:
10/18/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jovy Sarreal and Gilliana ShermanTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility does not have proper permit for renovation.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA met with Administrators Gilliana Sherman and Jovy Sarreal and explained the reason for the visit. The license was recently forfeited on 10/04/2021 and went through a Change of Ownership.

During the 09/27/2021 visit, the LPA conducted a tour at 11:00 a.m., interviewed staff at 11:03 a.m., 11:12 a.m., and 1:30 p.m, interviewed a resident at 11:31 a.m., and interviewed family members at 11:54 a.m. and 1:50 p.m. Today, the LPA interviewed staff at 11:17 a.m. and 11:20 a.m., and a resident at 11:25 a.m.

Regarding the allegation, it was alleged that the facility began renovations without the proper permit. Interviews confirmed that the facility renovated the kitchen from 09/07/2021 – 09/22/2021. Renovations included replacing cabinets, counter-tops, installing new appliances, and ceiling lighting. The Administrator produced documentation that demonstrated that a permit was necessary and obtained on 09/21/2021.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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-20210917132803
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 HOME CARE IV
FACILITY NUMBER: 565800711
VISIT DATE: 10/18/2021
NARRATIVE
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Based on the work completed, the LPA spoke with a representative from the City of Thousand Oaks Building Division on 09/27/2021 at 12:01 p.m., whom confirmed that a permit was required for the described work. The LPA reviewed the permit issued 09/21/2021, which noted kitchen remodel - plumbing gas line and electrical only.

Based off the information obtained, there is sufficient evidence to support the claim that at the start of renovations, the facility did not have a proper permit. This allegation is deemed Substantiated at this time.

Per the California Code of Regulations (CCR), Title 22, the following deficiencies were observed and cited: (Refer to LIC 9099-D). Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20210917132803
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 HOME CARE IV
FACILITY NUMBER: 565800711
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/18/2021
Section Cited
CCR
87305(a)
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87305(a) Alterations to Existing Building or New Facilities. Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement was not met as evidenced by:
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The Licensee agreed to do the following:
1. The Licensee obtained a permit amidst the renovation process. Licensee communicated that they would no longer initiate construction or renovations without seeking proper approval.
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Based on interview and record review, the licensee did not comply with the section cited above, as renovations were implemented without the necessary permit, which poses an immediate health and safety risk to residents in care.
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Plan of Correction met; this license was forfeited 10/04/2021
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC9099 (FAS) - (06/04)
Page: 3 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
09/17/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20210917132803

FACILITY NAME:THOUSAND OAKS HOME CARE IVFACILITY NUMBER:
565800711
ADMINISTRATOR:JOVY SARREALFACILITY TYPE:
740
ADDRESS:254 E. SIDLEE ST.TELEPHONE:
(805) 494-8860
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:0CENSUS: 0DATE:
10/18/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jovy Sarreal and Gilliana ShermanTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility does not serve meals of nutritional value and quality
Facility does not have a functioning kitchen.
Gas leaked resulting in setting off carbon monoxide detectors.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA met with Administrators Gilliana Sherman and Jovy Sarreal and explained the reason for the visit. The license was recently forfeited on 10/04/2021 and went through a Change of Ownership.

During the 09/27/2021 visit, the LPA conducted a tour at 11:00 a.m., interviewed staff at 11:03 a.m., 11:12 a.m., and 1:30 p.m, interviewed a resident at 11:31 a.m., and interviewed family members at 11:54 a.m. and 1:50 p.m. Today, the LPA interviewed staff at 11:17 a.m. and 11:20 a.m., and a resident at 11:25 a.m.

Regarding the allegation: Facility does not serve meals of nutritional value and quality
It was alleged that based on the kitchen renovation, the facility ordered take-out for meals, which caused concern regarding the nutritional value and quality of the food provided. Interviews with staff, residents, and responsible parties confirmed that breakfast and lunch were still prepared in the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20210917132803
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 HOME CARE IV
FACILITY NUMBER: 565800711
VISIT DATE: 10/18/2021
NARRATIVE
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The facility continued to utilize the refrigerator, microwave, and used the outdoor grill to serve meals for breakfast and lunch. Interviews confirmed that dinners were primarily ordered out because dinners and staff kept a record of what was ordered. A review of meals revealed that the food offered was of variety and had several options. Interviews with family members and residents revealed no complaints regarding what was provided and stated that dietary preferences were met. Whereas some meals indeed included pizza and Chinese food, the facility also ordered grilled chicken, salads, sandwiches, rice, noodles, and appropriate sides. A review of medical assessments for residents confirmed that there were no prescribed diets. Based on the information obtained, there is insufficient evidence to support the claim that during renovations, the facility did not serve meals of nutritional value and quality. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility does not have a functioning kitchen.


It was alleged that the facility did not have a functioning kitchen. It was confirmed that during the kitchen renovation, the facility still had use of the kitchen and microwave, and the staff used the outdoor grill to prepare meals. The facility provided most breakfasts and lunches, yet ordered out for dinner. As such, the facility implemented a plan in place to ensure that residents received three meals a day. Based on the information obtained, the facility continued to meet the resident care and dietary needs and ensured that residents received three meals a day during renovations, and the facility still had use of the refrigerator, microwave, and an outdoor grill as needed. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Gas leaked resulting in setting off carbon monoxide detectors.


It was alleged that during renovations, there was a gas leak that set off the alarm. Interviews confirmed that a gas line was accidentally touched by one of the contractors, but staff claimed that they identified the smell immediately, and asked the contractors to remedy the situation. Staff claimed that they tended to the issue ‘right away’, opened all the doors and windows, and ensured that all staff and residents were safe. Yet, other interviews confirmed that the smell was strong, that it lingered in the air for several minutes, and that there was elevated concern as gas emissions can be dangerous. There were inconsistencies communicated regarding whether the carbon monoxide detectors were triggered as a result of the gas, yet the majority of interviews claimed that no alarm was triggered. Based on the information obtained, there is insufficient evidence to support the claim that due to negligence, gas leaked into the facility which resulted in setting off carbon monoxide detectors. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6