565802416-12-16-2022-29-AS-JAPL-CMZ2SB-20230111163851

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802416
Report Date: 12/15/2022
Date Signed: 12/16/2022 08:21:49 AM

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
09/30/2022 and conducted by Evaluator Angel Ascencio

COMPLAINT CONTROL NUMBER: 29-AS-20220930132342

FACILITY NAME:	VILLA TERESA RESIDENTIAL CARE		FACILITY NUMBER:	565802416
ADMINISTRATOR:	VICTOR HERNANDEZ		FACILITY TYPE:	740
ADDRESS:	821 TERESA STREET		TELEPHONE:	(805) 604-7772
CITY:	OXNARD	STATE: CA	ZIP CODE:	93030
CAPACITY:	6	CENSUS: 6	DATE:	12/15/2022
		UNANNOUNCED	TIME BEGAN:	03:16 PM
MET WITH:	Victor Hernandez		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Staff spoke inappropriately to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angel Ascencio conducted a subsequent visit to deliver the finding to the above facility. LPA Ascencio met with Administrator Victor Hernandez and Marilou Rojas at 3:25 p.m. Entrance interview conducted.

On 09/30/2022, the Department received a complaint alleging that staff spoke inappropriately to residents. On 10/07/2022, LPA Ascencio conducted an interview with Staff #1 (S1), starting at 2:20 p.m. Interview with S1, revealed that on 09/30/2022, Resident #1 (R1) was sitting in the living room couch when a knock at the door was heard. S1 proceeded to open the door but, R1 was yelling at S1 to not open the door and get R1’s identification card (ID). S1 proceeded to open the door. R1 became upset yelling at staff to find the ID. R1 was receiving a packaged that needed R1’s ID. S1 stated that they were helping R1 get up from their chair.

Continued on LIC 9099 - C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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-20220930132342

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: VILLA TERESA RESIDENTIAL CARE	FACILITY NUMBER: 565802416
	VISIT DATE: 12/15/2022

NARRATIVE

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R1 accidentally kicked and knocked over a small tv tray that contained water, food and other miscellaneous items. S1 stated that R1 continued to yell at S1 stating S1 threw water at R1. S1 stated after that incident, they are not working with R1. That same day, interview with S2 starting at 2:30 p.m. revealed that in the morning of 09/30/2022, R1 was sitting in the living room when the doorbell rang. S1 began helping R1 get up from the couch. R1 kicked the tv tray by accident but was blaming S1 for the incident. S2 stated that R1 became very upset and started yelling at S1. S2 added that S1 no longer work with R1 because of that incident.

Later that same day, interview with R1 starting at 2:55 p.m. revealed that they were receiving a package a family member was sending. R1 continued, there was a knock at the door and S1 went to open the door. R1 stated they asked S1 to grab their ID card from their room but did not. R1 added, they asked S1 for help standing and S1 proceeded to grab and throw the tv dinner tray. R1 stated S1 began to yell profanity at R1. R1 continued, S2 was in the living room and told S1 to walk away. R1 finally stated that S1 no longer work with R1 since the day of the incident.

Although the allegation may have happened, there is not a preponderance of evidence to prove the alleged violation occurred; therefore the allegation is unsubstantiated.

Exit interview conducted and copy of the report provide to Admin via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC9099 (FAS) - (06/04)

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