565801892-1-3-2023-29-AS-DPEA-CN7QHV-20230118111143

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801892
Report Date: 01/03/2023
Date Signed: 01/03/2023 03:18:02 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
06/22/2022 and conducted by Evaluator Kelly Dulek

COMPLAINT CONTROL NUMBER: 29-AS-20220622123535

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: 35	DATE:	01/03/2023
		UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Luis Gonzalez		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Resident wandered away from the facility due to lack of supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegation listed above. LPA arrived at the facility at 01:02PM and met with Administrator Luis Gonzalez at 01:10PM. Entrance interview conducted.

During today's visit, LPA interviewed Administrator at 01:10PM, Assistant Administrator at 01:28PM,and toured the facility with Administrator at 01:57PM. During an initial complaint visit conducted on 06/29/2022, LPA interviewed Administrator at 11:35AM, door alarms were tested at 12:01PM, LPA toured the facility with Administrator at 12:04PM and LPA gathered copies of pertinent documents. Throughout the course of the investigation, LPA reviewed pertinent documents. The following was then determined:

The complaint alleges that Resident #1 (R1) eloped from the facility due to lack of supervision. Record review revealed that R1 is unable to leave the facility unassisted, is diagnosed with dementia, and is
Report Continued on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

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-20220622123535

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: 01/03/2023

NARRATIVE

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ambulatory. Previously, R1 had eloped from the facility on 04/08/2022. Following the 04/08/2022 elopement, staff had completed a new needs and service assessment for R1 identifying the need for additional supervision, including hourly checks. Then on 06/09/2022, R1's second elopement occurred, when R1 exited the building through an emergency exit around 05:00AM. Interview revealed that the elopement occurred just after staff had conducted their hourly checks and had recently observed R1 in their room. Staff were alerted by a door alarm, but were unable to locate R1 in or around the facility grounds. R1 was returned to the facility by the police at 08:20AM. Interview revealed that following the first elopement, R1's family was advised of R1's need for additional supervision and R1's family had been looking for alternate facility placement for R1. R1 subsequently moved out of the facility following the second elopement incident. Record review revealed that while the facility does have a plan of operation that includes a dementia care plan, the dementia care plan on file does not address elopement. LPA advised the Administrator to amend the current dementia care plan or to file an addendum to the dementia care plan to include elopement protocols and submit to CCLD for approval. Based on record review and interview, the allegation that "Resident wandered away from the facility due to lack of supervision" is deemed SUBSTANTIATED at this time.

The following deficiency was 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 deficiency may result in civil penalties.

Exit interview was conducted with Administrator Luis Gonzalez. Report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220622123535

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: 01/03/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/17/2023 Section Cited CCR 87464(f)(1)(c)	1 2 3 4 5 6 7	87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for...ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility added delayed egress on all upstairs stairwell doors. Additonally, facility added a camera in the downstairs exit stairwell, which alerts staff of any motion in that area. Administrator also agreed to author an addentum to the facility's dementia care plan to include elopement procedures. Addendum
	8 9 10 11 12 13 14	Based on interview and record review, R1 is not permitted to leave the facility unassisted, had a known elopement history, and eloped from the facility again, which poses an immediate safety risk to residents in care.	8 9 10 11 12 13 14	will be sent to CCL by 01/17/2023.
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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 Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

LIC9099 (FAS) - (06/04)

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