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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802430
Report Date: 11/16/2021
Date Signed: 11/16/2021 10:29:00 AM



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
11/09/2021 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20211109135558
FACILITY NAME:SELECT SENIOR LIVING IFACILITY NUMBER:
565802430
ADMINISTRATOR:HULL, DYLANFACILITY TYPE:
740
ADDRESS:1363 FEATHER AVETELEPHONE:
(805) 852-5059
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 4DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Dylan HullTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff has not posted the Ombudsman poster inside of the facility
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Ashley Smith and Elsie Campos arrived unannounced for an initial 10-day complaint visit. The LPAs met with Administrator Dylan Hull and explained the reason for the visit.

During today’s visit, the LPAs conducted a physical plant tour at 9:00 a.m. and spoke with the Administrator.

Regarding the complaint, it was alleged that the facility did not have the Ombudsman poster in the facility. During the physical plant tour, whereas it was observed that the number to the Long Term Care Ombudsman (LTCO) was posted in the entryway, the facility did not have the required Ombudsman poster in the entryway. During today’s visit, the Administrator instructed staff to obtain the poster from the LTCO Ventura Office. Based on the investigation, this allegation is deemed Substantiated at this time. See 9099-D for deficiencies. Exit interview conducted. A copy of the report and appeal rights were issued.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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 2
Control Number 29-AS-20211109135558
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: SELECT SENIOR LIVING I
FACILITY NUMBER: 565802430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/19/2021
Section Cited
CCR
87468.2(a)(10)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. The licensee shall post the telephone numbers and addresses for the local offices of the ...ombudsman program... conspicuously in the facility foyer, lobby, residents’ activity room, or other location easily accessible to residents
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The Administrator agreed to do the following:
1. During today's visit, staff went and obtained the poster. The poster was posted while the LPAs were in the facility.

Plan of Correction met.
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This requirement is not met as evidenced by:
Based on observation, the licensee did not comply with the section cited above, as the Ombudsman poster was not observed in the facility, which poses a potential health and safety risk to residents in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2