565801892-11-21-2024-29-AS-DPEA-DBE25C-20241126160520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801892
Report Date: 11/21/2024
Date Signed: 11/21/2024 03:11:20 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
10/30/2024 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20241030125452

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: 33	DATE:	11/21/2024
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Rose Gonzalez - Assistant Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff is refusing to repair facility walls.
Staff did not ensure facility A/C unit was properly installed.
Staff did not replace bathroom filters.
Staff did not keep facility free of vermin.
Staff are not properly caring for residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint visit to investigate the allegations liste above. Upon arrival LPA met with Assistant Administrator Rose Gonzalez and explained the reason for the visit.

On 11/01/2024 between 10:15 a.m. - 03:00 p.m. LPA conducted the initial complaint investigation. LPA conducted physical plant, interviewed staff, residents and reviewed and obtained copies of pertinent documentation relevant to the investigation. Today LPA conducted physical plant and interviewed staff.

It was reported that "Staff is refusing to repair facility wall" as it was alleged that there are cracks in the walls between rooms 14 and 13 as well as between rooms 18 and 19. Interviews with seven (7) staff members and six (6) residents revealed that none of the (13) people interviewed reported seeing any cracks in the walls. During the physical plant, LPA also did not find any cracks in the interior or exterior walls of the building.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

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 3

Control Number 29-AS-20241030125452

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: 11/21/2024

NARRATIVE

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Continued from 9099

Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff is refusing to repair facility wall” is deemed Unsubstantiated at this time.

It was reported that "Staff did not ensure facility A/C unit was properly installed" as it was alleged that the facility air conditioner unit is not working properly in the hallway between 204 and 206. Interviews and records revealed that the air conditioning units in the main lobby and kitchen were replaced within the last three months, however there were no air conditioner units replaced on the 2nd floor in the past three months. Interviews with seven (7) staff members and six (6) residents revealed that all (13) people interviewed have observed the A/C to function properly at this time. During the inspection, the Licensing Program Analyst (LPA) noted that the indoor temperature was set at 74 degrees Fahrenheit, while the outdoor temperature was 69 degrees Fahrenheit. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not ensure facility A/C unit was properly installed” is deemed Unsubstantiated at this time.

It was reported that "Staff did not replace bathroom filters" as it was alleged that filters in the two (2) public restrooms in the lobby are not functioning properly. During the inspection, the LPA did not find any filters in the bathrooms; however, there were exhaust fans present in each bathroom. The LPA inspected four (4) common area bathrooms and six (6) private bathrooms in randomly selected units and found that the exhaust fans were functioning properly at the time of the inspection Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not replace bathroom filter” is deemed Unsubstantiated at this time.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20241030125452

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: 11/21/2024

NARRATIVE

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Continued from 9099-C

It was reported that "Staff did not keep facility free of vermin" as it was alleged that mice and termites were observed in the facility. Interviews with seven (7) staff members and six (6) residents indicated that none of the 13 people interviewed have seen any mice or termites in the facility. A review of pest control invoices from the past three months showed that the pest control company visits the facility once a month to treat common areas. Additionally, there were no notes regarding the presence of mice or termites during these inspections. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not keep facility free of vermin” is deemed Unsubstantiated at this time.

It was reported that "Staff are not properly caring for residents in care," as it was alleged that residents are always complaining about staff. Interviews with six (6) residents in care indicated that none of them expressed any concerns about the level of care provided by the staff. Additionally, interviews with seven (7) staff showed that they were knowledgeable about residents' care needs, facility operations, and emergency procedures. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff are not properly caring for residents in care” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024

LIC9099 (FAS) - (06/04)

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