565801637-9-28-2023-29-AS-KLOZ-CX5VNL-20231031163518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801637
Report Date: 09/28/2023
Date Signed: 09/28/2023 04:05:23 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
09/20/2023 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20230920135710

FACILITY NAME:	VETERANS HOME OF CALIFORNIA-VENTURA		FACILITY NUMBER:	565801637
ADMINISTRATOR:	SELENA GARCIA LOPEZ		FACILITY TYPE:	740
ADDRESS:	10900 TELEPHONE ROAD		TELEPHONE:	(805) 659-7515
CITY:	VENTURA	STATE: CA	ZIP CODE:	93004
CAPACITY:	60	CENSUS: 56	DATE:	09/28/2023
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Selena Garcia Lopez		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff inappropriately spoke to a resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced initial 10-Day complaint visit to the facility at 12:20 p.m. the LPA was greeted by Cindy Gambill, Hospital Administrative Resident 2 (HOR2), and discussed the reason for the visit. Administrator Selena Garcia Lopez arrived shortly.

During today's visit the LPA obained copies of pertinent documents at 12:45 p.m. and interviewed three (3) residents, two (2) staff and the administrator between 01:00 p.m. and 3:15 p.m.

Report will continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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-20230920135710

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VETERANS HOME OF CALIFORNIA-VENTURA	FACILITY NUMBER: 565801637
	VISIT DATE: 09/28/2023

NARRATIVE

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Regarding the allegation, Staff spoke inappropriately to resident in care, it was alleged that on 09/16/2023, Staff #1 (S1) began yelling at Resident #1 (R1) as R1 walked towards the nursing station and yelled “They don’t give a shit about you!” It was further alleged that R1 reported the incident to S2, and S2 intervened and told S1 to stop yelling. During the investigation, R1 informed the LPA that S1 had yelled at them from the hallway and woken them up and confirmed that S1 yelled “They don’t give a shit about you.” A written statement made by S1 regarding the incident was provided to the LPA. S1 wrote that he spoke to the resident, “we don’t care about your shitty attitude. I am passing out meal orders and ensuring that you are safe and getting your meals.” Based on record review, since S1 admitted to speaking inappropriately to R1, there is sufficient evidence to support the allegation that staff spoke inappropriately to resident in care. The allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC9099-D).

Exit interview was conducted with the Administrator. A copy of the report and Appeal Rights were issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230920135710

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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: 09/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/06/2023 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1(a)(1) Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff...This requirment was not met as evidence by:	1 2 3 4 5 6 7	Administrator has agreed to review with staff (S1)the regulation 87468.1 (a)(1)-and send proof orself-verification via a letter to the CCLD department by 10/06/2023.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not comply with the section cited above when staff (S1) spoke to R1 inappropiately which posed a potential 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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
09/20/2023 and conducted by Evaluator Esther Cortez

COMPLAINT CONTROL NUMBER: 29-AS-20230920135710

FACILITY NAME:	VETERANS HOME OF CALIFORNIA-VENTURA		FACILITY NUMBER:	565801637
ADMINISTRATOR:	SELENA GARCIA LOPEZ		FACILITY TYPE:	740
ADDRESS:	10900 TELEPHONE ROAD		TELEPHONE:	(805) 659-7515
CITY:	VENTURA	STATE: CA	ZIP CODE:	93004
CAPACITY:	60	CENSUS:	DATE:	09/28/2023
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Selena Garcia Lopez		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff yelled at a resident while in care.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

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-20230920135710

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VETERANS HOME OF CALIFORNIA-VENTURA	FACILITY NUMBER: 565801637
	VISIT DATE: 09/28/2023

NARRATIVE

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Regarding the allegation, Staff yelled at residents while in care, it was alleged that on 9/16/2023 Staff #1 (S1) began yelling at Resident #1 (R1) as R1 walked towards the nursing station and yelled “They don’t give a shit about you!” It was further alleged that R1 reported the incident to S2, and S2 intervened and told S1 to stop yelling. During the investigation, R1 informed the LPA that S1 had yelled at them from the hallway and woken them up and confirmed that S1 yelled “They don’t give a shit about you.” The LPA was unable to interview S2, however was able to interview two additional residents. When asked if they have ever heard staff yelling at residents or to them, they stated that they had not heard staff yelling, nor had they been yelled at while in care. They stated, “staff is real great” and that staff are “pretty mellow”. In addition, Administrator Selena stated that even though S1 had admitted to speaking inappropriately to R1, S1 denied yelling at S1. Based on the information gathered on the above allegation, although the allegation may have happened or is valid, there was insufficient evidence to confirm that “Resident was yelled at while in care”. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of the report was provided to Administrator Selena.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

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