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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801637
Report Date: 10/27/2023
Date Signed: 06/27/2024 11:37:46 AM

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
10/25/2023 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20231025114008
FACILITY NAME:VETERANS HOME OF CALIFORNIA-VENTURAFACILITY NUMBER:
565801637
ADMINISTRATOR:SELENA GARCIA LOPEZFACILITY TYPE:
740
ADDRESS:10900 TELEPHONE ROADTELEPHONE:
(805) 659-7515
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:60CENSUS: DATE:
10/27/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Selena Garcia Lopez/ Cindy GambillTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Resident not being treated with dignity and respect
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced amended report to correct an error in the 10/27/2023 Complaint Investigation Report and to add additional information to the report.

Licensing Program Analyst (LPA) Esther Cortez arrived unannounced to conduct an initial 10-day complaint visit. The LPA met with Administrator Selena Garcia Lopez and explained the reason for the visit. Administrator Selena had to leave and instructed Cindy Gambill, Hospital Administrative Resident 2 (HOR2) to sing and review the report.

Today, the LPA interviewed two (2) staff and four (4) residents and reviewed documents between 10:50 a.m. and 3:30 p.m.

Report will contnue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
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-20231025114008
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: 10/27/2023
NARRATIVE
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Regarding the allegation, Resident not being treated with dignity and respect, it was alleged that on 08/20/2023, Staff #1 (S1) told Resident #1 (R1) that they were trying to fall to sue the facility. It was further alleged that R1 reported the incident to S2 and S2 reported the incident to management. The LPA observed that the Administrator had submitted an Unusual Incident Report (UIR) to document the above-mentioned interaction and/or incident. After review of the incident, on 08/28/23 the Administrator informed the LPA that they were in the process of reviewing the event. During the investigation, a written charting note made by S1 regarding the incident was provided to the LPA. S1 wrote that R1 had approached them and requested for R1’s walls to be checked for leaks, and no leakage was found. Later R1 had gone outside as they were “concerned about the downspout flooding outside”. S1 stated that they requested R1 to go back inside, which they did, and R1 later went back outside. S1 wrote they told R1 “maybe you are trying to hurt yourself here, so you can sue the home,” after they had requested for R1 to come inside again.

Additionally, Licensing Program Manager KaSandra Lopez conducted a telephone interview with S1 on March 13, 2024.

Based on record review, and interviews there is sufficient evidence to support the allegation that Resident not being treated with dignity and respect. The allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): Exit interview conducted and copy of the report and appeal rights provided to HOR2 Cindy Gambill.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20231025114008
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: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2023
Section Cited
CCR
87468.1(a)(1)
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Personal Rights. Each resident shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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Administrator stated S1 will be issued a letter of Instruction and received training on residents personal rights. Administrator agrees to submit proof by 11/10/23
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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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
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
10/25/2023 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20231025114008

FACILITY NAME:VETERANS HOME OF CALIFORNIA-VENTURAFACILITY NUMBER:
565801637
ADMINISTRATOR:SELENA GARCIA LOPEZFACILITY TYPE:
740
ADDRESS:10900 TELEPHONE ROADTELEPHONE:
(805) 659-7515
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:60CENSUS: DATE:
10/27/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Selena Garcia LopezTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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2
3
4
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Staff threatened resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Cortez arrived unannounced to conduct an initial 10-day complaint visit. The LPA met with Administrator Selena Garcia Lopez and explained the reason for the visit. Administrator Selena had to leave and instructed Cindy Gambill, Hospital Administrative Resident 2 (HOR2) to sing and review the report.

Today, the LPA interviewed two (2) staff and four (4) residents and reviewed documents between 10:50 a.m. and 3:30 p.m.

Report will contnue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
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-20231025114008
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: 10/27/2023
NARRATIVE
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Regarding the allegation, Staff threatened resident, it was alleged that on 08/20/2023 S1 threatened R1 to go inside their room or that they would contact the sheriff. It was further alleged that R1 reported the incident to S2 and S2 reported the incident to management. The LPA observed that the Administrator had submitted a Special Incident Report (SIR) to document the above-mentioned interaction and/or incident. To investigate the allegation, the LPA reviewed pertinent documents, and conducted resident and staff interviews. Interviews and record review revealed that S1 told R1 “if you don’t follow my directions, I’m going to call the Sheriffs.” However, interviews with S1 and R1 revealed that S1 had told R1 to step away from blocked off areas due to water leaking multiple times, and R1 had been asked to go inside their room multiple times due to safety concerns due to the hurricane and heavy rain on that day. Interview with one witness (W1) revealed that even though S1 did tell R1 to go inside their room or they would contact the sheriff, it was due to safety concerns. Lastly, all additional residents interviewed revealed that they feel safe and have no concerns regarding 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 “Staff threatened resident”. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5