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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801418
Report Date: 05/30/2024
Date Signed: 05/30/2024 08:32:31 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
05/29/2024 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20240529164940
FACILITY NAME:GAINSBOROUGH OAKSFACILITY NUMBER:
565801418
ADMINISTRATOR:MARIA L. MACANDILIFACILITY TYPE:
740
ADDRESS:91 W. GAINSBOROUGH ROADTELEPHONE:
(805) 777-8802
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 2DATE:
05/30/2024
UNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Maria L. MacandiliTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Staff are storing expired foods at the facility.
Facility does not have an emergency evacuation plan in place.
Staff did not ensure residents are provided nutritional meals.
Staff did not ensure facility is maintained clean.
Staff are not trained
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted complaint visit to the facility. Upon arrival LPA met with staff #1 and reason for the visit was stated. Administrator arrived at facility approximately 3:40 p.m. Reason for visit was explained and allegations were discussed.
On 05/29/2024, Community Care Licensing Division (CCLD) received a complaint with the above allegations. Investigation was initiated by Licensing Program Analyst (LPA) Zabel Chochian. LPA Chochian toured the facility with staff from approximately 2:45 p.m. – 3:00 p.m. Interview was conducted with staff from 3pm-3:30 p.m. Following is a summary of the investigation findings:
Regarding allegation, “Staff are storing expired foods at the facility” – The reporting party alleged that facility is storing expired canned foods. LPA conducted a tour of the kitchen and observed canned food items in the kitchen. A credible witness also provided information that facility is storing expired canned food items. Staff reported that they are checking all canned food items now and will dispose all expired cans. Based on observation of the expired canned food items in the kitchen and interviews, the allegation “Staff are storing expired foods at the facility” is deemed Substantiated at this time. (Continue to LIC 9099c).
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
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 4
Control Number 29-AS-20240529164940
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: GAINSBOROUGH OAKS
FACILITY NUMBER: 565801418
VISIT DATE: 05/30/2024
NARRATIVE
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Regarding allegation, “Facility does not have an emergency evacuation plan in place”. Information was provided that staff #1 was not able to provide facility emergency evacuation plan. Interview with staff #1 conducted during todays visit revealed that there is not a written evacuation plan or that he is not aware of any written plan. Administrator reported that she is working on completing one for the facility. Based on observation of the expired canned food items in the kitchen and interviews, the allegation “Facility does not have an emergency plan in place” is deemed Substantiated at this time.

Regarding allegation, “Staff did not ensure residents are provided nutritional meals”. Information was reported that staff do not plan meals a head and therefore do not provide resident quality food. It was reported that residents were served pasta and nothing else. LPA conducted interview with staff today and asked staff what residents had for lunch and staff stated “pasta”. LPA asked staff what’s for dinner and staff stated he doesn’t know yet. Interview with this staff confirmed that staff do not plan meals and serve resident meals not of good quality. LPA observed a piece of salmon in a container that was confirmed to be sitting out for over an hour. According to staff he was defrosting the salmon to cook for a resident. Based on observation of the facility food supply, and interview with staff, the allegation “Staff did not ensure residents are provided nutritional meals” is deemed Substantiated at this time.
Regarding allegation, “Staff did not ensure facility is maintained clean”. Information was received that facility is not maintained clean. LPA conducted a tour with staff and following was observed: kitchen cabinets stained/dirty; messy rooms with clothing and other belongings on the floor (photos taken); cob webs hanging from ceiling in rooms and hallway area; resident room ceiling stained (maybe due to leakage); resident door has blinds and are in disrepair (photo taken). Based on today’s observation, the allegation “Staff did not ensure facility is maintained clean” is deemed Substantiated at this time.

Regarding allegation, “Staff are not trained”. Information was received that staff #1 is unqualified to care for residents needs. LPA conducted interview with staff #1. Staff was able to communicate however when asked a certain question about the facility and training staff has received Staff #1 would refer to his wife (administrator). Staff #1 was unable to state what training he has completed; was not able to state facility evacuation/emergency plan. Staff said that they would just evacuate to the front. Administrator stated that she does not have training did not have any training records for staff #1. Based on interviews, the allegation “Staff are not trained” is deemed Substantiated at this time.
Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20240529164940
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: GAINSBOROUGH OAKS
FACILITY NUMBER: 565801418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2024
Section Cited
CCR
87555(a)
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The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. This requirement is not met as evidenced by:
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Licensee/Administrator shall develop a menu for resident meals to be served which are good quality and nutritional. Also provide in-service from outside vendor for training regarding General food service requirements.
Submit planned menu and scheduled training.
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Based on observation and interviews it was revealed resident are not provided with a nutritious meals. This poses a potiential health and safety hazard to resident in care.
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Type B
06/10/2024
Section Cited
CCR
87303(a)
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(a) 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 by:
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Licensee/Administrator agreed to make repairs and maintain facility clean at all times. Administrator shall provide photos of the facility kitchen (cabinets) cleaned ; common areas and each bedroom cleaned and organized.
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Based on observation facility observed with cobwebs; dusty and disrepair; resident rooms observed dusty; ceiling observed stained (water damage) kitchen cabinet dirty;
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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.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20240529164940
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: GAINSBOROUGH OAKS
FACILITY NUMBER: 565801418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2024
Section Cited
CCR
87212(a)
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87212 Emergency Disaster Plan
(a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.
This requirement is not met as evidenced by:
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Licensee/Administrator agreed to develop and submit the emergency disaster plan by 5/31/24.
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Based on interview with administrtor and staff it was revealed that Licensee/administrator has not yet completed an emergency disaster plan.
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Type A
05/31/2024
Section Cited
HSC
1569.625(a)b(c)
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(a) The Legislature finds that the quality of services provided to residents of residential care facilities for the elderly is dependent upon the training and skills of staff. It is the intent of the Legislature in enacting this section to ensure that direct-care staff have the knowledge...
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Licensee/Administrator agreed to hire a vendor to provide training to staff #1 according to Health and Safety code 1569.625(a)b(c). Locate and provide proof of trainer and schedule of training dates and times to be provided to staff #1. Also submit copy of certificates issued by vendor.
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(b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This requirement is not met as evidenced by:
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Based on interview with staff and Licensee it was revealed that staff #1 has not completed the required training.
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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4