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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800984
Report Date: 08/15/2024
Date Signed: 08/15/2024 02:14:08 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
07/08/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240708153245
FACILITY NAME:PHYLLIS FAMILY HOMEFACILITY NUMBER:
565800984
ADMINISTRATOR:LORRAINE MEDINAFACILITY TYPE:
735
ADDRESS:2445 EAST PHYLLIS STREETTELEPHONE:
(805) 581-0751
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:4CENSUS: 4DATE:
08/15/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lorraine Medina TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff is not CPR certified.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Brian Balisi conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted on 07/09/2024 by LPA M. Arroyo. On today's visit, LPA met with Administrator, Lorraine Medina. Entrance interview.

During the initial visit on 07/09/2024, LPA Arroyo conducted a plant tour at 8:01 a.m., conducted interviews with the Administrator and one (1) staff member between 8:05 a.m. and 9:10 a.m., conducted a staff file review at 9:33 a.m., and obtained copies of pertinent documents.
It was alleged that facility staff is not CPR certified. It was reported that staff does not attend CPR classes, but the Administrator signs them off as it they passed the course.

Record review and interviews conducted revealed that facility staff is currently certified for First Aid and CPR.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
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-20240708153245
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: PHYLLIS FAMILY HOME
FACILITY NUMBER: 565800984
VISIT DATE: 08/15/2024
NARRATIVE
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Continued from 9099

Interview conducted with the Administrator revealed that they are currently certified as an instructor for First Aid and CPR. The Administrator stated that facility staff take the course online for First Aid and CPR at their own pace. Once the staff has completed the course online, they are tested in person to make sure they understand the process in case of an emergency, and at this time they can also ask questions or get clarification. The Administrator stated that once the staff has demonstrated that they understand properly is when they will get certified for First Aid and CPR. Interviews conducted with staff revealed that they completed the course for First Aid and CPR before they began working as a staff at the facility. Staff stated that they went online and took the First Aid and CPR course which was about eight (8) hours long; however, they separated the sessions for a few days. The Administrator conducted a test to make sure I knew what to do in case of an emergency. It was not until after taking the test and passing that the Administrator approved my First Aid and CPR certification. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “facility staff is not CPR certified”. Therefore, this allegation is being deemed Unsubstantiated at this time.

Exit interview conducted. Report was reviewed and copy was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2