565800983-10-15-2021-29-AS-DPEA-C85V26-20211025160236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565800983
Report Date: 10/15/2021
Date Signed: 10/15/2021 04:11:21 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
11/20/2020 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20201120163246

FACILITY NAME:	LINA'S GUEST HOME		FACILITY NUMBER:	565800983
ADMINISTRATOR:	CELINA B. ALBUNA		FACILITY TYPE:	740
ADDRESS:	2221 KEPLER DRIVE		TELEPHONE:	(805) 487-3816
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 4	DATE:	10/15/2021
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Lina Albuna		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent complaint investigation to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted by LPA Lopez on 11/23/2020. During today’s visit, LPA Lopez met with Administrator Lina Albuna. Entrance interview conducted.

During the initial 10-day virtual inspection, the LPA conducted a FaceTime interview with Resident #1 (R1) at 2:23 PM, interviewed the administrator and conducted a physical plant tour. In addition, LPA requested pertinent records be faxed to the LPA. On 08/31/2021, the LPA conducted a subsequent in-person inspection at the facility. At 10:19 AM, the LPA observed Resident #1 (R1) in their bedroom watching TV. At 10:33 AM, the LPA began reviewing facility records for R1. At 12:16 PM, the LPA conducted an interview with R1 and at 12:25 PM the LPA conducted an interview with Administrator Lina Albuna.

Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

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-20201120163246

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: LINA'S GUEST HOME	FACILITY NUMBER: 565800983
	VISIT DATE: 10/15/2021

NARRATIVE

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The allegation alleges R1 has multiple pressure sores. Record review revealed, R1 has been receiving palliative care since approximately 09/08/2020. Additionally, the records reviewed did not reveal a history of any pressure injuries. A letter dated 11/28/2020, from the home health agency providing palliative care to R1 stated the resident has no bed sores or pressure injuries. Interviews conducted also revealed no history of pressure injuries on R1’s body. During the interviews, the LPA was advised R1 had issues pertaining to their right big toe. Records indicate R1 had a wound on the right toe as result of an open callus of which R1 was receiving treatment for by the home health agency. Based on the information obtained, there is insufficient evidence to support the allegation. Therefore, the allegation is unsubstantiated at this time.

Exit interview conducted and report reviewed with the administrator. A copy of the report will be emailed.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC9099 (FAS) - (06/04)

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