565801637-8-8-2022-29-AS-KHEN-CHCVMB-20220816163316

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801637
Report Date: 08/08/2022
Date Signed: 08/08/2022 02:01:53 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
08/05/2022 and conducted by Evaluator Ashley Smith

COMPLAINT CONTROL NUMBER: 29-AS-20220805125623

FACILITY NAME:	VETERANS HOME OF CALIFORNIA-VENTURA		FACILITY NUMBER:	565801637
ADMINISTRATOR:	JULIAN BOND		FACILITY TYPE:	740
ADDRESS:	10900 TELEPHONE ROAD		TELEPHONE:	(805) 659-7515
CITY:	VENTURA	STATE: CA	ZIP CODE:	93004
CAPACITY:	60	CENSUS: 57	DATE:	08/08/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Julian Bond		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility staff interacted with resident inappropriately

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct an initial 10-day complaint. The LPA met with Executive Director Julian Bond and explained the reason for the visit.

Today, the LPA interviewed staff at 10:17 a.m., 10:38 a.m., 10:59 a.m., 11:22 a.m., 12:35 p.m., and 12:42 p.m.; interviewed residents at 12:03 p.m., and 12:25 p.m., and reviewed documents.

Regarding the allegation: Facility staff interacted with a resident inappropriately
It was alleged that there was a verbal altercation between Staff #1 (S1) and Resident #1 (R1), in which S1 was observed speaking to R1 inappropriately. Interviews and records review confirmed that during a meeting that took place on approximately 7/21/2022, R1 allegedly became upset.

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: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

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-20220805125623

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: VETERANS HOME OF CALIFORNIA-VENTURA	FACILITY NUMBER: 565801637
	VISIT DATE: 08/08/2022

NARRATIVE

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Witnesses claimed that during the meeting R1 became visibly upset. R1 then came within several feet of S1 and yelled obscenities at S1. However, interviews conducted with S1, R1, and other parties supported claims that S1 engaged with R1 inappropriately during the meeting. Whereas S1’s statements were in response to the fact that R1 was yelling obscenities towards S1, the response to R1 was deemed unprofessional. It was communicated that it was out of character for S1 to speak out of turn. R1 has since apologized to S1 and other parties that were present during the meeting.

Based on the information obtained, there is sufficient evidence to support the claim that facility staff interacted with a resident inappropriately. This allegation is deemed Substantiated at this time.

The following deficiency was observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report, along with appeal rights, was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220805125623

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: VETERANS HOME OF CALIFORNIA-VENTURA	FACILITY NUMBER: 565801637
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/10/2022 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents ... shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agreed to do the following: 1. Administrator claimed that staff have reviewed the Employee Code of Conduct as a result of the 7/21 incident. Additional training will take place for S1. Proof of completion to be submitted to CCL before 8/10/2022.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not comply with the section cited above, as S1 engaged with R1 inappropriately and unprofessionally, which poses an immediate personal rights 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: 08/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022

LIC9099 (FAS) - (06/04)

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