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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801979
Report Date: 06/09/2024
Date Signed: 06/09/2024 09:49:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
05/30/2024 and conducted by Evaluator Esther Cortez
COMPLAINT CONTROL NUMBER: 29-AS-20240530163427
FACILITY NAME:WELLNESS CARE SENIOR LIVINGFACILITY NUMBER:
565801979
ADMINISTRATOR:MARIA HERNANDEZFACILITY TYPE:
740
ADDRESS:158 ROCKAWAY ROADTELEPHONE:
(805) 649-5143
CITY:OAK VIEWSTATE: CAZIP CODE:
93022
CAPACITY:56CENSUS: 21DATE:
06/09/2024
UNANNOUNCEDTIME BEGAN:
05:43 PM
MET WITH:Maria HernandezTIME COMPLETED:
09:55 PM
ALLEGATION(S):
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Uncleared staff working at the facility
INVESTIGATION FINDINGS:
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At 05:43 p.m. Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent complaint visit to the facility. LPA met with staff and explained the reason for the visit. Administrator Maria Hernandez arrived shortly thereafter.

On 05/31/2024 , the LPA obtained copies of pertinent records. During today's visit the LPA conducted staff interviews and a file review.

Report will continue on LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2024
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-20240530163427
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: WELLNESS CARE SENIOR LIVING
FACILITY NUMBER: 565801979
VISIT DATE: 06/09/2024
NARRATIVE
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On the allegation: Uncleared staff is working at the facility. It was alleged that Staff was working at the facility without fingerprint clearance. To investigate the complaint LPA Cortez conducted a physical tour, interviews and conducted record review. During the tour of the facility the LPA observed which staff were present at the facility. The LPA reviewed the Licensing Information System facility personnel report summary and compared them with the facility's Personnel report LIC500 and schedule, as well as verified the staff working during today's visit. During today's visit the LPA also searched for all four staff on the Guardian background check system with the names and information provided by staff, records and administrator. After review of information gathered it was confirmed that three (3) out of four (4) staff (S1, S2, S3) who were working during today's visit were working without a fingerprint clearance and were not associated to the facility. In addition one (1) out of four (4) staff (S4) had a fingerprint clearance, however were not associated to the facility. During today's visit the Administrator was not able to provide records for three (3) staff (S1, S2, S3), which will be addressed under a separate cover. Administrator stated that all four staff have been working at the facility on and off for the past couple of months.

Based on the information gathered, the above allegation "Uncleared staff is working at the facility" is deemed substantiated at this time. Therefore citation (LIC 9099D) with civil penalty is issued at this time pursuant to Title 22 regulations. Exit interview conducted. Copy of report and appeal rights provided.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20240530163427
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WELLNESS CARE SENIOR LIVING
FACILITY NUMBER: 565801979
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2024
Section Cited
CCR
87355(e)(1)
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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department or ...This requirement is not met as evidenced by:
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The Administrator has agreed to do the following: Obtain verification from DOJ Background Check Bureau to show that all staff are cleared prior to working at the facility. Staff will not work at the facility until they are cleared.
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Based on observation,& record review the licensee did not comply with the section cited above as three out of four staff did not have a criminal record clearance, and one out of four was not associated which poses an immediate health, safety or personal rights risk to persons in care.
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And will ensure that all staff have a criminal record clearance and are associated to facility prior to employment. Administrator will submit self certification of above for plan of correction.
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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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3