565801892-9-8-2023-29-AS-DPEA-CW3LBR-20230927083709

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801892
Report Date: 09/08/2023
Date Signed: 09/08/2023 01:10:09 PM

Unsubstantiated

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
12/28/2022 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20221228100841

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: 34	DATE:	09/08/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Luis Gonzalez		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Facility staff did not return a wheelchair to a resident.
Facility staff did not adequately supervise resident resulting in resident getting injured by another resident.5

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegations. The initial visit was conducted on 01/03/2023 by LPA K. Dulek and a subsequent visit was conducted on 08/01/2023 by LPA M. Arroyo. During today's visit, LPA met with Administrator, Luis Gonzalez and the reason for the visit was explained. Entrance interview.

During the initial visit on 01/03/2023, LPA Dulek toured the facility at 1:57 p.m. interviewed the Administrator at 1:10 p.m. and obtained copies of pertinent documents. On 08/01/2023, LPA Arroyo conducted interviews with the Administrator and three residents between 9:45 a.m. and 10:30 a.m and obtained a copy of the census.

(Report Continued on LIC 9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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-20221228100841

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: 09/08/2023

NARRATIVE

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(Report Continued from LIC 9099...)

It was alleged that facility staff did not return a wheelchair to resident. It was reported that Resident #1’s (R1’s) wheelchair was taken away during a fire inspection by the fire department and never returned. Review of documents revealed that R1’s Physician’s Report dated 09/02/2021 indicates R1 to be ambulatory without needing assistance of any medical equipment to get around. Interviews conducted with staff revealed the facility had had a fire inspection and the inspector stated the hallways needed to be clear at all times. Additionally, after R1 had asked for their wheelchair, it was given back as it was placed in storage. The wheelchair did not have a name for staff to easily identify and say it belonged to R1 until R1 described the wheelchair and then after, the wheelchair was taken out from storage and taken to R1’s apartment. Interviews conducted with R1 revealed the facility had mentioned to R1 that the fire inspector stated wheelchairs and other large items were a fire hazard if left unattended in the hallway. Additionally, although R1 is ambulatory, R1 stated they used a wheelchair to easily maneuver around the table while doing puzzles and playing cards without having to get out of the chair. R1 also stated the facility returned the wheelchair to them shortly after R1 mentioned the incident, as the wheelchair had stickers that R1 had placed on the wheelchair before it had gone missing, which allowed the facility to locate the wheelchair in storage. Furthermore, R1’s wheelchair has since been returned to R1. Based on the interviews conducted with R1 and facility staff, the Department does not have sufficient evidence to support the allegation of “facility staff did not return a wheelchair to resident”. Therefore, this allegation is deemed Unsubstantiated at this time.

(Report Continued on LIC 9099C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20221228100841

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: 09/08/2023

NARRATIVE

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(Report Continued from LIC 9099C...)

It was also alleged that facility staff did not adequately supervise residents resulting in resident getting injured by another resident. It was reported that R1 was assaulted by Resident #2 (R2) during an activity which caused R1 to have a skin tear on their arm. Interviews conducted with staff revealed that R1 had reported the incident to management as R1 sustained a skin tear after arguing with R2. Interviews conducted with R1 revealed that during the incident, R2 accidentally caused R1 to have a small skin tear. Additionally, R1 added that R2 apologized following the incident and realizing R1 had a skin tear. Similarly, both R1 and R2 stated the incident was caused by a misunderstanding between both residents. Furthermore, during interviews conducted with R1 and R2, both residents reported having no concerns with the facility staff and stated staff is always present during activities. Based on interviews conducted with staff and residents, the Department does not have sufficient evidence to support the allegation of “that facility staff did not adequately supervise residents resulting in resident getting injured by another resident”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the appeal rights and report were issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC9099 (FAS) - (06/04)

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