565801300-2-10-2023-29-AS-JAPL-CP3VZR-20230215155310

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801300
Report Date: 02/10/2023
Date Signed: 02/10/2023 10:44:02 AM

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
02/09/2023 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20230209094902

FACILITY NAME:	HOME SWEET HOME CARE		FACILITY NUMBER:	565801300
ADMINISTRATOR:	GLORIA P. VALENCIA		FACILITY TYPE:	740
ADDRESS:	7520 VAN BUREN STREET		TELEPHONE:	(805) 659-4427
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 6	DATE:	02/10/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Gloria Valencia and Rosie Gonzales		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Due to lack of supervision, resident left the facility grounds unattended

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ashley Smith arrived unannounced at 9:20 a.m. to conduct an initial 10 day visit. The LPA met with staff and explained the reason for the visit. Administrator Gloria Valencia was unavailable to come to the visit. Today, the LPA toured the facility, reviewed documents, interviewed staff at 9:31 a.m., 9:39 a.m., 9:40 a.m., 10:13 a.m., and 10:21 a.m.

Regarding the above allegation, it is alleged that the resident wandered from the facility unattended due to lack of care and supervision. Interviews and a review of video surveillance confirmed that on 02/06/2023 at approximately 12:30 p.m., Resident #1 (R1) walked out of the facility and traveled across the street. R1 was approximately three (3) minutes out of the facility before being discovered by Staff #1 (S1). Video surveillance and interviews noted that S1 assisted R1 back to the facility. The LPA also noted that R1’s physician report dated 01/11/2023 indicates that R1 exhibits wandering behavior. Staff confirmed that there were two staff on shift on 02/06/2023; however, Staff #2 (S2) indicated that S1 did not inform them that R1 left the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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-20230209094902

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: HOME SWEET HOME CARE	FACILITY NUMBER: 565801300
	VISIT DATE: 02/10/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The LPA spoke with S1 over the phone at 10:21 a.m., who alleged that R1 was pacing back and forth and wanted to go outside. S1 alleged that they did not want to agitate R1, and alleged that they watched R1 leave the facility, and watched R1 walk across the street. S1 said they then decided to go across the street to remind R1 that it was not their home, and guided R1 back to the facility. S1 alleged that they were still 'keeping eyes' on R1. The LPA explained that if they claimed they were supervising R1, they have to be alongside or close to R1. The LPA explained that staying in the facility and watching R1 cross the street is not appropriate supervision, and reminded S1 that R1 could not leave the facility unassisted.

The LPA reviewed resident records at 9:34 a.m. and per the physician reports for all residents, reports indicated that 6/6 residents are unable to leave the facility without assistance.

Based on the information obtained, there is sufficient evidence to support the claim that facility staff did not adequately supervise R1. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview conducted, today's reports and appeal rights were reviewed and issued. The Administrator authorized staff to sign the report.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20230209094902

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: HOME SWEET HOME CARE	FACILITY NUMBER: 565801300
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/13/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator has agreed to do the following: 1. Submit a Plan of Action, communicating the steps staff will take to ensure that residents will not leave the facility unassisted. Review this protocol with staff. Submit protocol and sign-in sheets to CCL no later than 2/13/2023.
	8 9 10 11 12 13 14	Based on interview and records review, the licensee did not comply with the section cited above, as the facility failed to ensure that R1 did not leave the facility unassisted per the physician report, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3