565801979-5-12-2022-29-AS-DPEA-D5T3W5-20240531183603

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565801979
Report Date: 05/12/2022
Date Signed: 05/12/2022 08:22:35 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
05/04/2022 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20220504134133

FACILITY NAME:	WELLNESS CARE SENIOR LIVING		FACILITY NUMBER:	565801979
ADMINISTRATOR:	ALEIDA ALONSO		FACILITY TYPE:	740
ADDRESS:	158 ROCKAWAY ROAD		TELEPHONE:	(805) 649-5143
CITY:	OAK VIEW	STATE: CA	ZIP CODE:	93022
CAPACITY:	56	CENSUS: 28	DATE:	05/12/2022
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Maria Hernandez		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Staff did not receive proper training

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) JoAnn Rosales and KaSandra Lopez conducted an unannounced initial 10 day complaint inspection at the facility today. The LPAs met with Administrator Maria Hernandez at 10:55 AM and explained the reason for today's inspection.

During today's inspection, the LPAs conducted a physical plant tour with the Administrator beginning at 11:00 AM. Interviews were conducted with facility staff and residents between 12:44 PM and 4:49 PM. At 3:50 PM, the LPAs also began record review.

Record review revealed Staff #1 S1 (S1) only has eight hour of documented medication training in file. Interviews with the Administrator revealed they conducted 20 hours of hands-on shadowing with S1 but there is no documentation to support this occurred. Interviews also revealed S1 does assists residents with medications. Report continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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-20220504134133

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: WELLNESS CARE SENIOR LIVING	FACILITY NUMBER: 565801979
	VISIT DATE: 05/12/2022

NARRATIVE

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Based on this information there is sufficient evidence to support the allegation of "Staff did not receive proper training" occurred. Therefore, the allegation is deemed substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations and/or Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D). Exit interview was conducted, today's reports and appeal rights were reviewed and emailed to the Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220504134133

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: WELLNESS CARE SENIOR LIVING	FACILITY NUMBER: 565801979
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/23/2022 Section Cited HSC 1569.69(a)(1)	1 2 3 4 5 6 7	§1569.69 (a)(1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training and 8 hours of other training or instruction,... which shall be completed within... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator agrees S1 will not pass medications until they obtain 16 hours of documented hands on medication training. The training shall be submitted to CCL by 05/23/2022.
	8 9 10 11 12 13 14	Based on record review and interviews, the licensee failed to comply with the section cited above as one staff (S1) did not have record of 16 hours of hands on shadowing prior to passing medications which poses a potential health and safety risk to residents 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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC9099 (FAS) - (06/04)

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