565800906-6-16-2021-29-AS-KHEN-C5B3YD-20210726183943

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800906
Report Date: 06/16/2021
Date Signed: 06/16/2021 02:23:56 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
06/10/2021 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20210610110654

FACILITY NAME:	GOLDEN YEARS CARE		FACILITY NUMBER:	565800906
ADMINISTRATOR:	LARRY WAYNE		FACILITY TYPE:	740
ADDRESS:	1325 LANTANA STREET		TELEPHONE:	(805) 383-1188
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 4	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	10:38 AM
MET WITH:	Larry Wayne		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility denied access to Ombudsman

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Angel Ascencio and Kelly Dulek conducted an unannounced initial complaint inspection at the facility today. The LPAs arrived at 10:38AM and met with Administrator Larry Wayne. The LPAs informed the Administrator of the reason for today's inspection.

During today's visit, LPAs Dulek and Ascencio conducted an interview with Administrators/Licensees Teresita and Larry Wayne at 10:45AM, facility tour with Administrator at 11:18AM, and requested copies of documents pertinent to the investigation. The following was then determined:

Interview revealed that an Long Term Care Ombudsman (LTCO) representative came to the facility on 6/8/2021 at 3:30PM. At that time, Larry Wayne was not at the facility, but was reached by telephone. When LTCO came to the door, Teresita Wayne called Larry Wayne and the LTCO representative was not allowed to gain entry into the facility. During today's visit, LPAs were provided with copies of a letter from Resident #1 (R1)'s POA dated 12/16/2020 indicating a request for "Ombudsman representative follow the same

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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-20210610110654

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: GOLDEN YEARS CARE	FACILITY NUMBER: 565800906
	VISIT DATE: 06/16/2021

NARRATIVE

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precautions we do and not enter the facility." A second undated letter from Resident #2 (R2)'s POA indicates a request that "Ombudsman services, and any other service providers, continue to be suspended at Golden Years Care while COVID risk is still present." However, the letter appears to have been sent with an email dated 4/23/2021. On 12/14/2020, LPA Dulek had called and spoken with Administrator Larry Wayne regarding LTCO entry to the facility and current guidelines. On 12/14/2020, LPA reiterated that at that time, according to Ventura County Public Health guidelines, LTCO were allowed access to the facility following the Public Health guidelines. On 4/21/2021, LPA Dulek, along with Licensing Program Manager (LPM) Kristin Heffernan participated in a phone call with Administrator Larry Wayne in regards to LTCO access to the facility. At that time, LPA and LPM indicated to Administrator that there are no guidelines restricting LTCO access to the facility. During today's interviews, Administrator indicated that families are allowed to visit residents indoors at this time, however families do not want LTCO services. LPA was unable to confirm the validity of this request, due to the outdated letters provided to LPA during this visit. Additionally, PIN 21-17.2-ASC dated 5/14/2021 states "This visitation waiver shall not apply to essential visits, which shall include the following...Visits mandated by a court order or federal law such as visits by Adult Protective Services or the Long-Term Care Ombudsman." Therefore, based on interviews, the allegation that "facility denied access to Ombudsman" is deemed SUBSTANTIATED at this time.

Exit interview conducted. Today's reports and appeal rights were reviewed and provided via email to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210610110654

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: GOLDEN YEARS CARE	FACILITY NUMBER: 565800906
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/17/2021 Section Cited HSC 87468.1(a)(11)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)...have all of the following personal rights: (11) To have their visitors including ombudspersons...visit privately during reasonable hours...provided that the rights of other residents are not infringed upon. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to review and post PIN 21-17.2-ASC. Administrator will notify all residents' responsible parties of the current guidelines reflected in this PIN via email and will provide CCL a copy of the email by POC due date.
	8 9 10 11 12 13 14	Based on interviews and observation, the facility did not allow Ombudsman access to the facility on 6/8/2021, which poses an immediate personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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