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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 02:17:03 PM

Substantiated


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
07/05/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240705161544
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:Lorraien Medina TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Licensee does not ensure that clients are adequately fed
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 Arroyo 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., observed the kitchen and food pantry starting at 8:09 a.m., conducted interviews with the Administrator, one (1) staff member, and two (2) residents between 8:05 a.m. and 9:10 a.m., conducted a file review at 9:15 a.m., and obtained copies of pertinent documents relevant to the investigation.

It was alleged that licensee does not ensure that clients are adequately fed. It was reported that the facility does not have sufficient food and staff does not have fresh nutritious foods for the clients.
Substantiated
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 3
Control Number 29-AS-20240705161544
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

During the walkthrough on 07/09/2024, LPA observed perishable foods that were expired as well as moldy which included red potatoes, sweet potatoes, cilantro, lactaid milk (exp 07/07/2024), reduced fat milk (exp 07/06/2024), donuts (best if used before 07/01/2024), pasta sauce (best if used by 12/2023), and refried beans (best if used by 04/2024). LPA also observed a large pot of black beans with a piece of aluminum on top with no date visible anywhere. During interviews, staff was unable to determine date for black beans being cooked. Interviews conducted with residents revealed that cereal and milk are served for breakfast every day although the menu posted indicates Sunday is “cereal day”. During an interview with the Administrator, the Administrator stated that grocery shopping is done every Tuesday and stated that they had just gone grocery shopping; however, was unable to show receipts for grocery shopping that were current and within a week.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were 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 3
Control Number 29-AS-20240705161544
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2024
Section Cited
CCR
87555(b)(8)(b)
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The following food service requirements shall apply: (8) All food shall be of good quality... Food in damaged containers shall not be accepted, used or retained. T

This requirement is not met as evidenced by:
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The Administrator will ensure all food is audited and anything expired and/or rotten will be discarded. The Administrator discarded all expired food at the time of the visit. POC has been met.
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Based on LPA observation, the licensee did not comply with the section cited above, as perishable foods were observed expired and/or rotten, which poses a potential health and safety risk to persons in care.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3