565801892-6-24-2021-29-AS-KHEN-C4FPWD-20210629114035

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801892
Report Date: 06/24/2021
Date Signed: 06/24/2021 05:01:44 PM

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
06/17/2021 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20210617105621

FACILITY NAME:	FILLMORE COUNTRY CLUB		FACILITY NUMBER:	565801892
ADMINISTRATOR:	LUIS GONZALEZ		FACILITY TYPE:	740
ADDRESS:	827 RIVER STREET		TELEPHONE:	(805) 524-5080
CITY:	FILLMORE	STATE: CA	ZIP CODE:	93015
CAPACITY:	66	CENSUS: 40	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	10:57 AM
MET WITH:	Luis Gonzalez		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Administrator hit resident's leg with a door.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted an unnanounced initial 10-day complaint inspection for the allegation listed above. LPA met with Administrator at 10:57 AM. LPA discussed the reason for today's visit.

LPA interviewed Admin at 11:00 AM. LPA and Admin conducted a physical plan tour at 11:03 AM, obtained copy of resident roster sheet at 11:35 AM, conducted interview betweem 11:39 AM and 12:04PM.

Regarding the allegation: Administrator hit residents leg with door. During resident interview, R1 stated the door was locked when in the restroom. Once R1 was done, R1 unlocked the door to exit. At that time, Admin came in without knocking, hitting R1's left leg.

Continued on LIC 9099 - C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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-20210617105621

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: FILLMORE COUNTRY CLUB	FACILITY NUMBER: 565801892
	VISIT DATE: 06/24/2021

NARRATIVE

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During admin interview, admin stated he headed to the restroom, did not knock, opened the door and hit something, but wasn't sure whether it was R1's leg or wheelchair. Based on the interviews, there is sufficient evidence to support the claim; Administrator hit resident's leg with door, as administrator admitting hitting the resident with the door. Therefore, this allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20210617105621

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: FILLMORE COUNTRY CLUB	FACILITY NUMBER: 565801892
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/24/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/25/2021 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All facilities(a)(3)Residents in all residential care facilities for the elderly shall have all of the following personal rights:To be free from punishment, humiliation, intimidation, abuse, or other actions....	1 2 3 4 5 6 7	Administrator stated he will provide a written statement of what they will do to prevent accident from happending again regarding regulation 87468.1(a)(3).
	8 9 10 11 12 13 14	Based on LPA's observations, the licensee did not comply with the section cited above as administrator admitted hitting R1 with door which poses an immediate health risk to persons 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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

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
06/17/2021 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20210617105621

FACILITY NAME:	FILLMORE COUNTRY CLUB		FACILITY NUMBER:	565801892
ADMINISTRATOR:	LUIS GONZALEZ		FACILITY TYPE:	740
ADDRESS:	827 RIVER STREET		TELEPHONE:	(805) 524-5080
CITY:	FILLMORE	STATE: CA	ZIP CODE:	93015
CAPACITY:	66	CENSUS: 40	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	10:57 AM
MET WITH:	Luis Gonzalez		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Administrator did not treat resident with dignity.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted an unnanounced initial 10-day compaint inspection fo the allegation listed above. LPA met with Administrator at 10:57 AM. LPA discussed the reason for today's visit.

LPA interviewed Admin at 11:00 AM. LPA and Admin conducted a physical plan tour at 11:03 AM, obtained copy of resident roster sheet at 11:35 AM, conducted interviews betweem 11:39 AM and 2:05 PM.

Regarding the allegation: Administrator did not treat resident with dignity. During today's visit, LPA conducted resident interviews with R1 starting at 11:39 AM, R2 starting at 12:04 PM, R3 starting at 12:15 PM, R4 starting at 12:49 PM, and R5 starting at 2:05 PM. Based on the investigation, there is insufficient evidence to support the claim that Administrator did not treat resident with dignity. This allegation is Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. Report provided via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021

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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