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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801892
Report Date: 04/11/2022
Date Signed: 04/12/2022 08:41:49 AM


Document Has Been Signed on 04/12/2022 08:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:FILLMORE COUNTRY CLUBFACILITY NUMBER:
565801892
ADMINISTRATOR:LUIS GONZALEZFACILITY TYPE:
740
ADDRESS:827 RIVER STREETTELEPHONE:
(805) 524-5080
CITY:FILLMORESTATE: CAZIP CODE:
93015
CAPACITY:66CENSUS: 39DATE:
04/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:18 PM
MET WITH:Luis GonzalezTIME COMPLETED:
05:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angel Ascencio conducted a Case Management visit regarding an elopement that occurred on 4/8/22 for the above facility. LPA met with Administrator Luis Gonzalez.

During the investigation. LPA interviewed Admin Luis Gonzalez and Administrative Assistant at 3:20 p.m and Staff #1 (S1) at 5:00 p.m. During the interviews, it was revealed that Resident #1 (R1) was sitting in the patio enjoying the sun. Staff went to their room to pick up tray after lunch and was not present. Staff went out to look for R1 around 12:40 p.m. at the patio and realized they were not there. S1 decided to walk to daughter place because they live close by and Admin Assistant took company van. Around 12:50 p.m., R1 was located about 1 block away from community alone with no supervision and no noted injuries. R1 was physically in the community at 12:55 p.m. LPA received a telephone call from Admin on 04/08/2022 at approximately 4:37 p.m. regarding the elopement incident. Interview with R1 could not be conducted as R1 was busy with other needs. LPA reviewed R1's LIC 602 Physician's Report dated 02/02/2022, it was revealed that R1 has a diagnosis of Dementia and a box was checked off by the Physician stating " Can't leave facility unattended." LPA also reviewed incident report dated 4/8/22, R1's Admission Agreement, Plan of Care and the facilities Plan of Operation regarding caring for Dementia Residents.

1 citations was issued during today’s visit. The following deficiencies were observed (See LIC 809-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, citation page and appeal rights was provided via email to Admin.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/12/2022 08:41 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2022
Section Cited

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87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.


This requirement is not met as evidenced by:
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The facility did not comply with the section cited above as R1 left the facility unattended and was found 1 block away from the facility which posses and immediate health, safety and peronnal rights risk to person in care.
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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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
LIC809 (FAS) - (06/04)
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