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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565800984
Report Date: 03/20/2025
Date Signed: 03/20/2025 02:28:11 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
08/22/2024 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20240822151642
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:
03/20/2025
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Lorraine MedinaTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Licensee does not allow resident to visit at facility
Licensee spoke inappropriately to a resident
Licensee did not obtain consent from resident regarding the use of video surveillance
Licensee retaliated against a resident for filing a complaint
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced subsequent complaint visit at the facility today, with the purpose of delivering findings for the above listed allegations. LPA arrived at 01:40PM and initially met with facility staff. Licensee Lorraine Medina was contacted via telephone and arrived at 01:55PM. LPA informed Licensee of the reason for today's inspection. Entrance interview conducted.

During an initial complaint visit conducted on 08/28/2024, LPAs Dulek and Byrne conducted a facility tour at 09:35AM, an interview with Licensee at 09:52AM, file review at 10:14AM, resident and staff interviews from 11:46AM to 01:00PM and gathered copies of documents pertinent to the investigation. Throughout the course of the investigation, LPA Dulek reviewed all documents gathered and interviewed additional relevant parties telephonically. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
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-20240822151642
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: 03/20/2025
NARRATIVE
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Allegation: “Licensee does not allow resident to visit at facility:”

The complaint alleges that the licensee does not allow Resident #1 (R1) to have visitors at the facility. Staff and resident interviews revealed that residents are allowed to have visitors at the facility. The Licensee has asked if a visitor will be staying overnight or will be staying later into the evening, then the resident inform the Licensee. However, all parties interviewed indicated visitors are allowed on premises at the facility. Interview with R1 revealed that R1 has had their family members visit and while typically R1’s family members stay in the car, if they wanted to they can come into the facility and visit. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation "Licensee does not allow resident to visit at facility" is deemed Unsubstantiated at this time.

Allegation: “Licensee spoke inappropriately to a resident:”

The complaint alleges that the licensee spoke inappropriately to R1. Reporting party indicated they have not directly heard the licensee speak inappropriately to R1, however R1 reported to the reporting party that it happened. During interview with the LPAs, R1 also reported that the licensee found medications in R1’s room that R1 had obtained from the community. When the licensee found the medications, the licensee told R1 they cannot keep medications in their room and according to R1, the licensee was “yelling” and “was pissed.” A meeting was set up with R1’s service coordinator related to the resident bringing over the counter medications into the facility. The licensee denied the allegation. Other staff and clients interviewed, including the reporting party and R1 all indicated that no one has been observed to be mean or raising their voice at R1 or the other residents in care. R1 reported that the licensee has been nice to R1 since then. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation "Licensee spoke inappropriately to a resident" is deemed Unsubstantiated at this time.

Allegation: “Licensee did not obtain consent from resident regarding the use of video surveillance:”

The complaint alleges that there was a camera installed in R1’s room, which R1 did not want nor did R1 consent to. Interview with R1 revealed that when R1 had moved back into their room at the facility, R1 Report Continued on LIC 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240822151642
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: 03/20/2025
NARRATIVE
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noticed a camera in their room. R1 indicated it was up in the corner of their room and it looked like a light bulb. LPA inquired about the camera and it’s whereabouts at the time of the complaint visit. R1 stated they had given the camera to Staff #1 (S1) when they had discovered it and informed S1 of their concerns. Interview with S1 revealed that S1 did not have the alleged camera in their possession, nor did S1 observe the camera at all. R1 described the camera as “looking like a lightbulb” and containing wires. R1 indicated they removed the camera from the room and did not have it to show the LPAs. LPAs observed the common areas and all resident rooms at the facility. LPAs observed cameras outside the facility, however, no cameras were observed inside the facility. Licensee stated there have never been cameras inside the facility and the object in question was actually a light, therefore no video consent was obtained nor needed. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation " Licensee did not obtain consent from resident regarding the use of video surveillance" is deemed Unsubstantiated at this time.

Allegation: “Licensee retaliated against a resident for filing a complaint:”

The complaint alleges that after R1 voiced concerns about the food in the facility, that the Licensee retaliated against R1. All residents interviewed indicated they have not observed any retaliation against R1 nor any other residents in care. Even R1 stated no one has retaliated and no one has been mean. R1 also indicated that if R1 calls their service coordinator again, the licensee is “going to be pissed.” Staff indicated they have not observed any retaliation against any clients either. No specific examples were provided by the reporting party nor R1 of what the alleged retaliation entailed. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation " Licensee retaliated against a resident for filing a complaint" is deemed Unsubstantiated at this time.

No citations issued. Exit interview conducted. A copy of today’s report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3