565801291-8-30-2022-29-AS-DPEA-CNCUFT-20230123143315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801291
Report Date: 08/29/2022
Date Signed: 08/30/2022 11:33:41 AM

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
03/22/2022 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20220322142450

FACILITY NAME:	CACCAM'S STANTON RESIDENCE		FACILITY NUMBER:	565801291
ADMINISTRATOR:	KIRSTIE CACCAM THOMPSON		FACILITY TYPE:	740
ADDRESS:	3726 STANTON COURT		TELEPHONE:	(805) 582-0504
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 6	DATE:	08/29/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Venis Caccam		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff hit resident
Staff is verbally abusive to residents in care

INVESTIGATION FINDINGS:

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A subsequent complaint visit was conducted today to deliver the final report. Following is summary of the investigation: On 3/21/2022, it was alleged that Staff #1 (S1) hit resident #1 (R1) and called R1 “stupid”. Reporting party confirmed that R1 was checked and there were no visible bruising. On 3/30/2022 from approximately 11AM-1:15PM, LPA met with and interviewed staff and residents in the home. Facility staff and random residents interviewed denied allegations. Staff interviewed denied the allegations and reported that they have never been verbally or physically aggressive with any of the residents. Residents interviewed denied the allegations and reported feeling safe in the home. Residents did not report any mistreatment by any facility staff. Ms. Caccam confirmed that she did not witness any of her staff be verbally or physically aggressive with the residents. No other witnesses could be identified to the alleged incident. S1 denied allegations. Other staff interviewed reported they did not witness such incident. R1 denied the allegations and reported that staff are nice; R1 reported feeling safe at the facility and is not mistreated by any of the staff. Based on the information gathered, allegations “Staff hit resident” and “Staff is verbally abusive to residents in care” are deemed unsubstantiated at this time. Exit interview held. Copy of report issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

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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