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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801423
Report Date: 09/09/2025
Date Signed: 09/09/2025 01:26:08 PM

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
03/11/2025 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20250311090359
FACILITY NAME:HOUSE OF TRANSITIONFACILITY NUMBER:
565801423
ADMINISTRATOR:TIFFANY CURTISFACILITY TYPE:
772
ADDRESS:1750C SOUTH LEWIS ROADTELEPHONE:
(805) 437-2903
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:15CENSUS: 15DATE:
09/09/2025
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Francine FigueroaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff mishandling residents medication.
Staff not administering residents medication as prescribed.
Staff did not properly store medication.
Staff is not adequately trained.
Staff does not provide scheduled activities for residents.
Staff not keeping hallway free of obstruction.
Insufficient staffing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 03/17/2025 by LPAs M. Arroyo and V. Conway, and a subsequent visit was conducted on 07/09/2025 by LPA M. Arroyo. On today’s visit, the LPA met with Residential Program Manager, Francine Figueroa. Entrance interview conducted.

During the initial visit on 03/17/2025, the LPAs conducted a plant tour starting at 11:35 a.m., conducted an interview with one staff at 11:30 a.m., observed the centrally stored medications area and conducted a medications review starting at 11:47 a.m., and obtained copies of pertinent documents relevant to the investigation. On 07/09/2025, between 10:45 a.m. and 11:50 a.m., LPA Arroyo conducted interviews with two staff and three clients, conducted a medication review, and obtained copies of pertinent documents relevant to the investigation.

Report Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
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-20250311090359
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: HOUSE OF TRANSITION
FACILITY NUMBER: 565801423
VISIT DATE: 09/09/2025
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff is mishandling residents’ medication and staff is not administering residents’ medication as prescribed. It was reported that there have been medication errors due to facility staff administering wrong dosages and medications not administered as prescribed. During the medication review conducted on 03/17/2025, the LPAs did not identify any discrepancies in the medication records. All three (3) clients' medications and the Centrally Stored Medication and Destruction Records (CSMDR) were reviewed, and documentation indicated that medications are being administered as prescribed. The LPAs conducted pill counts for three (3) randomly selected clients, and the counts matched the corresponding documentation. During staff interviews, it was revealed that, during medication administration, staff read the medication name and dosage aloud to the clients. Staff reported that clients are responsible for removing their own medications from the packaging, while staff supervise to ensure accuracy and prevent errors. Additionally, staff stated that the pharmacy provides a copy of the CSMDR for each client’s routine medications. Client interviews corroborated with staff interviews as clients confirmed that they pop their medications themselves as staff read the instructions aloud. Furthermore, clients did not express any concerns regarding their medications. Based on the information obtained through medication review and observation, the Department has insufficient evidence to support the allegations of “staff is mishandling residents’ medication” and “staff is not administering residents’ medication as prescribed”. Therefore, these allegations are deemed Unsubstantiated at this time.

It was also alleged that staff did not properly store medication. It was reported that medications were not being properly stored and secured. During the facility walkthrough, the LPA observed that the medication room was locked upon arrival. Additionally, inside the medication room, the medication cart was also observed to be locked. Interviews conducted with facility staff confirmed that the medication cart remains locked at all times, with the only exception being during active medication administration. Furthermore, the facility follows a schedule for distributing medications to clients during each shift. Based on LPA observations and interviews conducted, the Department has insufficient evidence to support the allegation of “staff did not properly store medication”. Therefore, this allegation is deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20250311090359
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: HOUSE OF TRANSITION
FACILITY NUMBER: 565801423
VISIT DATE: 09/09/2025
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Report Continued from LIC 9099C...

It was also alleged that staff is not adequately trained. It was reported that facility staff are not adequately trained and unqualified to be administering medications to residents and safety drills are not being conducted quarterly. Per facility program, in Policy Title: Personnel Authorized for Medication Administration, it states under Procedure that “Medication is not administered by Casa staff. Residential Recovery Counselors are authorized to assist clients with medication self-administration…”. Additionally, per Policy Title: Ongoing Staff Training it states that “this program requires all staff complete 20 hours of training on an annual basis. There are certain trainings that are required on an annual basis and these trainings are incorporated into the program for ongoing staff training”. Record review of yearly staff trainings revealed that each staff member has at least 20 hours of training which includes medication training along with other training specific or related to their job specification. Additionally, record review of facility’s emergency disaster plan revealed that emergency disaster drills are being conducted quarterly as per regulation. Furthermore, record review and interviews conducted indicate that emergency disaster drills are being conducted at least once a month. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff is not adequately trained”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was also alleged that staff does not provide scheduled activities for residents. It was reported that there is no curriculum scheduled for residents to follow. During a facility walkthrough, the LPA observed an Activity Calendar posted in the common area, listing at least three (3) different activities scheduled each day. Additionally, clients were observed actively participating in group activities at the time of the visit. Interviews with staff revealed that a treatment plan is developed for each client, specifying the number of hours they are expected to participate in activities each week. Staff reported that clients are encouraged, but never forced, to participate in specific activities. Client interviews corroborated this, as clients confirmed that while they are expected to complete a certain number of participation hours each week, they are not required to attend any particular activity. Additionally, clients stated that the facility offers a wide variety of activities, and they have no difficulty meeting their weekly hours, as they enjoy participating in many of the group activities. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff does not provide scheduled activities for residents”. Therefore, this allegation is deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20250311090359
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: HOUSE OF TRANSITION
FACILITY NUMBER: 565801423
VISIT DATE: 09/09/2025
NARRATIVE
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Report Continued from LIC 9099C...

It was also alleged that staff are not keeping hallway free of obstruction. It was reported that there are brooms and other objects in the hallways creating a hazard and concern for residents’ safety. During the visit on 03/17/2025, the LPA, along with the Residential Program Manager, conducted a walkthrough of the facility. The following was observed: the facility has a janitorial closet, which was locked and inaccessible to clients at the time of the visit. Brooms, mops, and other cleaning supplies were observed stored inside the janitorial closet. Staff interviews confirmed that all brooms and mops are properly stored when not in use. Furthermore, all hallways were observed to be clean and free of any obstructions. Based on observations and interviews, the Department has insufficient evidence to support the allegation of “staff not keeping hallway free of obstruction”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was further alleged that there is Insufficient staffing. It was reported that staff is rotated between facilities; however, there are not enough to cover all houses. Per facility program, in Policy Title: Staffing it states that One (1) Residential Recovery Counselor is scheduled for the Casa on the day shift and two (2) Residential Recovery Counselors are scheduled on the evening and night shifts seven days a week. During the course of the investigation, the LPA obtained and reviewed timecards and staff schedules for the month of February 2025 and conducted interviews with both staff and clients. At the time of the complaint, there were at least two staff members scheduled for each shift in the AM, PM, and NOC shifts. Timecards confirmed that, although staff schedules varied, there was sufficient staffing to cover any unforeseen shortages. Record review and interviews further revealed that additional staff were available on-call, and outside agency staffing was also utilized as needed. Staff interviews indicated that staffing levels were consistently adequate as they were fully staffed. Staff reported that there were typically two to three staff members scheduled for each shift. In addition, facilities had floaters available who were able to move throughout the premises and provide assistance where needed. Client interviews confirmed the presence of two to three staff members per shift, including during the NOC shift. Additionally, three out of three clients interviewed reported no concerns regarding staffing or living at the facility. Furthermore, a review of Guardian records verified that all staff were fingerprint-cleared and associated with all on-site facilities, allowing them to work double shifts or be reassigned to different facilities as necessary. Based on the information obtained and reviewed during the course of the investigation, the Department has insufficient evidence to support the allegation of “insufficient staffing”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview. A copy of the report was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4