565802411-5-31-2022-29-AS-DPEA-CFTLEG-20220628084128

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802411
Report Date: 05/31/2022
Date Signed: 05/31/2022 10:41:45 AM

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
05/23/2022 and conducted by Evaluator Martha Guzman-Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20220523095227

FACILITY NAME:	ANITA'S CARE VILLA		FACILITY NUMBER:	565802411
ADMINISTRATOR:	SHAFFER, JENNIFER		FACILITY TYPE:	740
ADDRESS:	521 LOUIS DRIVE		TELEPHONE:	(805) 716-3633
CITY:	NEWBURY PARK	STATE: CA	ZIP CODE:	91320
CAPACITY:	6	CENSUS: 3	DATE:	05/31/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Jennifer Shaffer		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility failed to provide resident's records to resident's authorized representative

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted an initial 10-day complaint visit to the above facility. Upon arrival, LPA Guzman Chavez met with Administrator Jennifer Shaffer and explained the reason for the visit. Entrance interview conducted.

During today’s visit, the LPA toured the facility at 9:15 a.m., interviewed the Administrator at 9:30 a.m., and obtained copies of pertinent documents relevant to the investigation.

It was alleged that on 05/18/2022, “Facility staff failed to provide resident's records to resident's authorized representative.” It was reported that on 5/16/2022, a letter requesting all medical records was sent to Anita’s Care Villa by the law firm representing the Power of Attorney (POA) of a resident. Additionally, the Authorization for the Release of Medical Information was also attached to the request.

Continued on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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-20220523095227

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: ANITA'S CARE VILLA	FACILITY NUMBER: 565802411
	VISIT DATE: 05/31/2022

NARRATIVE

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Continued from LIC 9099...

During the course of the investigation, it was revealed that documents were not released to the requesting party within the time allotted by regulations. Furthermore, interviews and documentation reviewed revealed that the request made by the POA’s representative was received by the facility on 5/18/2022. Additional interviews revealed that facility had reached out to POA’s representative to acknowledge request being received; however, they felt they would not be able to gather all documents together by the deadline given as there were hundreds of pages. Review of documents revealed that resident’s files and medical records were not provided to the POA’s representative by 5/20/2022. Based on interviews and documents obtained and reviewed, the allegation “Facility failed to provide resident's records to resident's authorized representative is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency will be cited (refer to LIC 9099-D)

Exit interview conducted, citations issued, appeal rights discussed, and a copy of this report sent via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220523095227

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: ANITA'S CARE VILLA	FACILITY NUMBER: 565802411
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/03/2022 Section Cited CCR 87468.2(19)	1 2 3 4 5 6 7	87468.2(19) Additional Personal Rights of Residents in Privately Operated Facilities. (19)To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee has agreed to provide LPA with tracking number of documents mailed to POA Representative, which will be delivered by today 5/31/2022 and will submit a Statement of Understanding detailing the importance of Regulation 87468.2 and submit by 6/03/2022.
	8 9 10 11 12 13 14	Based on interviews and record review, the licensee did not meet the section cited above as they failed to produce records requested by POA’s Representative, which poses a potential risk to the personal rights of 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: Martha Guzman-Chavez	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC9099 (FAS) - (06/04)

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