565801327-3-14-2022-29-AS-DPEA-CCHRQT-20220314131404

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801327
Report Date: 02/11/2022
Date Signed: 03/14/2022 11:56:31 AM

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
11/13/2020 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20201113114027

FACILITY NAME:	GOLDEN ACRES RCFE II		FACILITY NUMBER:	565801327
ADMINISTRATOR:	BABY JANE ANGELES		FACILITY TYPE:	740
ADDRESS:	1673 WILLOWBROOK LANE		TELEPHONE:	(805) 813-6411
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	5	CENSUS: 3	DATE:	02/11/2022
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Gerald Junio, Staff		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility is not kept clean
Facility is in disrepair, broken oven
Facility staff did not keep hazardous items inaccessible to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted an subsequent complaint visit to deliver final investigation finding regarding above allegations. During today’s visit LPA Chochian met with staff Gerald Junio. Administrator was contacted and reason for visit as explained.

On 11/13/2020, a complaint was received through credible witness regarding facility being in disrepair and unclean; and hazardous items being accessible to residents.

Following is a summary of the investigation:
On 11/19/2020, LPA Chochian conducted the initial complaint visit. Due to the situation surrounding the Corona Virus Disease 2019 (COVID-19), and to implement mitigation measures, the initial complaint investigation was conducted telephonically with Administrator Jane Angeles between the hours from 3p.m. to 4:45 p.m. Allegations above were discussed. On 11/19/2020, LPA and Administrator conducted a virtual tour of the facility physical plant areas including but not limited to the facility kitchen area. (continue to LIC9099c)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

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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Control Number 29-AS-20201113114027

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: GOLDEN ACRES RCFE II	FACILITY NUMBER: 565801327
	VISIT DATE: 02/11/2022

NARRATIVE

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LPA observed grease stains on the cabinets and microwave; stove oven door handle observed broken. Administrator and staff reported that since there is no hood above the stove the grease sets on the cabinets and therefore is hard to remove. Administrator stated that they will be replacing the microwave above the stove with a hood soon. Administrator reported that she had staff clean all the cabinets with a degreasing spray. Regarding the oven door administrator reported that it was repaired and will soon be replaced with a new stove/oven.

Regarding allegation – Facility staff did not keep hazardous items inaccessible to residents – Information was received through a credible witness that during a visit they observed the chemical and sharps cabinets in the kitchen area unlocked accessible to residents and everyone. There was only one staff present attending to residents at the time and staff had to have walked away from the kitchen, leaving cabinets containing chemicals/sharps unlocked to open the front door for this person/witness.
Based on the above information obtained and observation made by LPA and credible witness allegations above are deemed substantiated at this time.

Pursuant to Title 22 CA Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).
Exit interview conducted. Copy of report and appeal rights provide to Administrator by email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20201113114027

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: GOLDEN ACRES RCFE II	FACILITY NUMBER: 565801327
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/11/2022 Section Cited CCR 87705(f)(1)(2)	1 2 3 4 5 6 7	(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements......cleaning supplies and disinfectants. This requirement is not met as evidenced	1 2 3 4 5 6 7	Administrator instructed staff to lock kitchen cabinets storing cleaning supplies and sharps when walking away. In-service provide to staff.
	8 9 10 11 12 13 14	Based on observation and interview - facility staff did not comply with above. Cabinets containing cleaning supplies and sharps were observed unlocked accessible to residents in care. This posed an immediate health and safety risk for residents in care.	8 9 10 11 12 13 14
Type B 02/11/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced	1 2 3 4 5 6 7	Administrator direct staff to clean kitchen area and cabinets. Administrator stated moving forward staff will maintain facility clean and in good repair at all times. Photo submitted. In-services training provided to staff.
	8 9 10 11 12 13 14	Based on observation and interview - facility staff did not comply with above. Kitchen area and cabinets observed with lots of grease stains. This posed a potential health and safety risk for residents in care.	8 9 10 11 12 13 14

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: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022

LIC9099 (FAS) - (06/04)

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