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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801393
Report Date: 10/06/2021
Date Signed: 10/06/2021 04:26:39 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
08/03/2021 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20210803150520
FACILITY NAME:GONZALES FAMILY HOMEFACILITY NUMBER:
565801393
ADMINISTRATOR:VENIE G. GONZALESFACILITY TYPE:
735
ADDRESS:4450 BROWNING DRIVETELEPHONE:
(805) 488-2315
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 5DATE:
10/06/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Venie GonzalesTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff hit resident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) KaSandra Lopez conducted an unannounced subsequent complaint investigation inspection at the facility today. Tri-Counties Regional Center Quality Assurance Specialist (QAS) Liz Aced-Arnett was also present. The LPA and QAS arrived at the facility at 11:40 AM and advised staff of the reason for today's inspection. Administrator Venie Gonzales arrived at 12:20 PM.

The complaint investigation regarding the above allegation began on 08/06/2021. On this date, record review was conducted at 3:12 PM and an interview with Staff #2 (S2) at 3:37 PM was conducted.
On 08/20/2021, a subsequent inspection was conducted. The LPA attempted to interview Resident #1 (R1) at 12:08 PM, conducted interviews with Staff #3 (S3) and Staff #4 (S4) beginning at 12:15 PM and conducted a telephone interview with Staff #1 (S1) at 12:40 PM. On this date, a telephone interview was also conducted with Witness #1 (W1).
On 09/13/2021, the LPA obtained a copy and reviewed the 08/02/2021 Oxnard Police Department Case Report regarding the incident. Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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 5
Control Number 29-AS-20210803150520
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: GONZALES FAMILY HOME
FACILITY NUMBER: 565801393
VISIT DATE: 10/06/2021
NARRATIVE
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During today’s inspection, the LPA and QAS conducted interviews with the Administrator Venie Gonzales at 12:20 PM, Sam Gonzales, Administrator of the licensee's other licensed home and direct support person, at 12:49 PM and Staff # (S2) 1:29 PM.

Interviews and record review revealed on 08/02/2021, R1 was on the floor in the living room after attempting to walk unassisted. R1 recently had a surgery and needs assistance ambulating. S2 was the only staff in the living room with R1 and Resident #2 (R2) when R1 had fallen. S2 called S1 for assistance. W1 entered the living room area from another part of the home, after hearing R1 yell. S1 came from the other room and picked R1 off the floor and placed them back on to a seat in the living room. After doing this, S1 hit R1 on the head with an open hand which was observed by two individuals. The hit to the head reportedly made an audible sound heard from a few feet away. Law enforcement was contacted by one of the individuals and S1 was cited by the police officer on 08/02/2021. No physical injuries were observed on R1. S1 was placed on administrative leave after the incident and continues to remain on leave.

During the interview with S1 they admitted to tapping R1 on the head after picking R1 up off the floor. S1 stated they did so because they were worried and concerned that R1 may have hurt them self when they tried to get up and did not mean to cause harm to R1. S1 stated they have been R1’s caregiver for 13 years.

Based on the information, there is sufficient evidence to support the allegation of staff hit resident. Therefore, the allegation is substantiated. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted and report reviewed with Venie Gonzales. A copy of the report and appeals rights will be emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/03/2021 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20210803150520

FACILITY NAME:GONZALES FAMILY HOMEFACILITY NUMBER:
565801393
ADMINISTRATOR:VENIE G. GONZALESFACILITY TYPE:
735
ADDRESS:4450 BROWNING DRIVETELEPHONE:
(805) 488-2315
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 5DATE:
10/06/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Venie GonzalesTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff got angry with resident
Staff pushed resident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) KaSandra Lopez conducted an unannounced subsequent complaint investigation inspection at the facility today. Tri-Counties Regional Center Quality Assurance Specialist (QAS) Liz Aced-Arnett was also present. The LPA and QAS arrived at the facility at 11:40 AM and advised staff of the reason for today's inspection. Administrator Venie Gonzales arrived at 12:20 PM. On 04/12/2022, this report was amended due to a clerical error, which does not change the original complaint findings of unsubstantiated issued on the LIC 9099-C on 10/06/2021.
The complaint investigation regarding the above allegation began on 08/06/2021. On this date, record review was conducted at 3:12 PM and an interview with Staff #2 (S2) at 3:37 PM was conducted.
On 08/20/2021, a subsequent inspection was conducted. The LPA attempted to interview Resident #1 (R1) at 12:08 PM, conducted interviews with Staff #3 (S3) and Staff #4 (S4) beginning at 12:15 PM and conducted a telephone interview with Staff #1 (S1) at 12:40 PM. On this date, a telephone interview was also conducted with Witness #1 (W1). On 09/13/2021, the LPA obtained a copy and reviewed the 08/02/2021 Oxnard Police Department Case Report regarding the incident. Report continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20210803150520
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: GONZALES FAMILY HOME
FACILITY NUMBER: 565801393
VISIT DATE: 10/06/2021
NARRATIVE
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During today’s inspection, the LPA and QAS conducted interviews with the Administrator Venie Gonzales at 12:20 PM, Administrator of the licensee's other licensed home, Sam Gonzales at 12:49 PM and Staff # (S2) 1:29 PM.

The allegations allege S1 got angry with R1 when they fell and needed assistance and S1 pushed R1. Interviews revealed S2 was the only staff in the living room with R1 and Resident #2 (R2) when R1 had fallen. S2 then called S1 for assistance. Witness #1 entered the living room, after hearing R1 yell in the living room. Based on the interviews, there is insufficient evidence to support the allegations occurred. Therefore, the allegations are deemed unsubstantiated at this time.

Exit interview and amended report reviewed with Venie Gonzales over the telephone on 04/12/2022. A copy of the report was emailed for signature.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20210803150520
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: GONZALES FAMILY HOME
FACILITY NUMBER: 565801393
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2021
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights (a)...each client shall have personal rights which include, but are not limited to, the following:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule,....
This requrirement is not met as evidenced by:
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On the 08/06/2021, the administrator submitted proof all staff received personal rights training and training regarding their hands off policy. Plan of correction is cleared.
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Based on interviews, the licensee did not comply with the section above as interviews revealed S1 hit R1 on the head with an open hand which poses an immediate safety risk to residents 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: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5