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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802430
Report Date: 09/09/2022
Date Signed: 09/09/2022 03:12:06 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
09/08/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220908153854
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:
09/09/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dylan HullTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility did not follow resident's admission agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial 10-day visit. The LPA met with House Manager Tracy Varnell and Administrator Dylan Hull and explained the reason for the visit.

During today’s visit, the LPA interviewed staff at 9:50 a.m., 10:10 a.m., 10:35 a.m., and 10:40 a.m.; toured the kitchen area at 9:55 a.m., and obtained documents.

Regarding the allegation: Facility did not follow resident's admission agreement.
It was alleged that the licensee failed to follow the admission’s agreement regarding Resident #1 (R1). A review of documentation indicated that documents were signed on 7/11/2022. Per the admission’s agreement, there is a non-refundable pre-admission’s fee of $7500. However, it was decided that R1’s responsible party would pay a pre-admission fee of $3750, at a 50% discounted rate.
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: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
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 5
Control Number 29-AS-20220908153854
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
VISIT DATE: 09/09/2022
NARRATIVE
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A review of the signed admission’s agreement indicated the above-mentioned amount. However, R1 moved out of the facility on 8/17/2022. Per the agreement, as the contract was terminated during the second month of residency, R1 would be entitled to a refund of 60% of the balance after a $500 deduction. It was alleged that as of today, R1 had not received a refund per the admission agreement.

In addition, concerns were raised due to the claim that R1 was charged a full month’s rent from 8/15/2022 – 9/14/2022, even though R1 was moved out of the facility on 8/17/2022. R1’s responsible party provided notice to the licensee on 8/15/2022 that R1 would be moving out of the facility. Interviews confirmed it was not a 30 day notice, but notice that R1 would be leaving the facility immediately. However, per the admission’s agreement, ‘if the Resident leave the facility other than a medical condition, a thirty (30) day notice to the facility is required’. If the thirty-day notice is not provided, the remaining 30 days are due to the facility. Interviews confirmed that R1 moved out of the facility on 8/17/2022, two days after providing notice to the facility. In addition, whereas R1 moved into the facility on 7/15/2022, paperwork was signed on 7/11/2022. Per the documents and interview, the room was designated for R1 as of 7/11/2022.

Based on the information obtained, whereas R1 is responsible for paying the remaining thirty (30) days as R1's responsible party did not provide thirty (30) day notice to the facility, R1 is entitled to a partial refund of the pre-admission fee, even though the pre-admission fee was decided upon at a discounted rate. The allegation ‘facility did not follow resident’s admission’s agreement’ is Substantiated at this time.

See 9099-D for deficiencies. Exit interview conducted. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20220908153854
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: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/16/2022
Section Cited
HSC
1569.651(h)(3)
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1569.651(h)(3) Preadmission fee or deposit for elderly at residential care facilities. (3) If the resident leaves the facility for any reason during the second month of residency, the resident shall be entitled to a refund of at least 60 percent of the preadmission fee amount in excess of five hundred dollars ($500).
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The Administrator agreed to do the following:
1. Issue the refund as required per regulation. Inform CCL when this has happened, but no later than 9/16/2022
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This requirement is not met as evidenced by;
Based on interview and record review, the licensee did not comply with the section cited above for Resident #1 (R1) as they moved out during the 2nd month of residency and did not receive a refund, which poses a potential personal rights 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: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
09/08/2022 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20220908153854

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:
09/09/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dylan HullTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility did not serve resident fresh and nutritious foods while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for an initial 10-day visit. The LPA met with House Manager Tracy Varnell and Administrator Dylan Hull and explained the reason for the visit.

During today’s visit, the LPA interviewed staff at 9:50 a.m., 10:10 a.m., 10:35 a.m., and 10:40 a.m.; toured the kitchen area at 9:55 a.m., and obtained documents.

Regarding the allegation: Facility did not serve resident fresh and nutritious foods while in care.
It was alleged that the facility lacked fresh fruits and vegetables and residents were served ‘frozen, pre-packaged food’. During today’s visit, the LPA observed the breakfast and lunch service. For breakfast, each resident had a serving of mixed berries, along with eggs, sausage, and an English muffin. For lunch, the residents had soup and a half sandwich.
Unsubstantiated
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: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20220908153854
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
VISIT DATE: 09/09/2022
NARRATIVE
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 Staff interviews revealed that residents have the option to have fresh fruit and vegetables throughout the day. Staff admitted that residents will also eat food items such as lasagna, sandwiches, different proteins and so on, but stated that they also will attempt to customize meal options per the preference of the resident.

Interviews and records review revealed that R1 was on mechanical/chopped diet. However, R1 did not have specific restrictions on food items that they could or could not eat. The LPA observed both refrigerators on the property and observed an abundance of raspberries, strawberries, and blueberries, as well as fresh vegetable options for resident consumption. The LPA also observed oranges, bananas, and apples on the counter in good condition. At the time of the visit, the facility had a sufficient supply of perishable and non-perishable food. A review of the facility menu displayed a variety of foods that was of good quality and quantity. It was communicated that grocery shopping takes place weekly, and staff are able to obtain a variety of fresh foods as needed and/or requested. Staff admitted that if concerns were raised regarding what R1 was consuming, it was more so due to preference and not necessarily due to an inability to provide nutritious and food of good quality to R1.

Based on the information obtained, there is insufficient evidence to support the claim that the facility did not serve resident fresh and nutritious foods while in care. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5