<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802444
Report Date: 05/19/2023
Date Signed: 05/19/2023 12:41:09 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
06/08/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20220608091739
FACILITY NAME:LAND OF ENCHANTMENT 1 BOARD AND CARE LLCFACILITY NUMBER:
565802444
ADMINISTRATOR:ROXANA LARAFACILITY TYPE:
740
ADDRESS:78 W GAINSBOROUGH RDTELEPHONE:
(805) 601-5202
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Markdel Estrada - CaregiverTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility did not provide written notice to the resident for rate increase
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**This is an amended report that updates the findings of one of the allegations on the report that was issued on 10/20/2022**

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent visit to continue the investigation of the allegations listed above. Upon arrival LPA met with Staff Markdel Estrada and explained the reason for the visit. Estrada called Licensee Roxana Lara who stated Markdel can sign for the report.

On 6/9/2022, between 9 a.m. – 3 p.m., LPA conducted the initial 10-day complaint visit. LPA conducted physical plant, reviewed and obtained pertinent documents relevant to the investigation as well as interviewed staff, residents, outside agencies and families of residents in care. On 10/20/2022, LPA conducted physical plant, interviewed staff, responsible parties and conducted medication audit for (4) residents in care.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
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 6
Control Number 29-AS-20220608091739
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: LAND OF ENCHANTMENT 1 BOARD AND CARE LLC
FACILITY NUMBER: 565802444
VISIT DATE: 05/19/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099

It was alleged that facility did not provide written notice to Resident 1 (R1) or R1’s responsible party for rate increase. Interviews conducted and records reviewed revealed, the rent increased for R1 in January 2022 and March 2022. LPA did not observe any document in the residents file that indicated a rental increase notification was provided to R1 or R1’s responsible party. Additionally, interviews conducted with the administrator revealed that R1s responsible party was provided with a written notice however, administrator was not able to provide any proof that a written letter was issued. Interviews with responsible parties of other residents in care along with resident records review revealed that other responsible parties have received verbal and written notification (60) days prior to their rate increases. Based on interviews conducted and records review, the department has sufficient evidence to determine that facility did not provide written notice to R1 for rate increase. Therefore, the above allegation has been deemed SUBSTANTIATED at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220608091739
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: LAND OF ENCHANTMENT 1 BOARD AND CARE LLC
FACILITY NUMBER: 565802444
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
Section Cited
HSC
1569.655(a)
1
2
3
4
5
6
7
(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents...provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase...with residents. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to submit a statement of understanding, detailing how the facility will maintain compliance of HSC 1569.655(a) and send to LPA via email by COB 05/26/2023.
8
9
10
11
12
13
14
Based on interviews and documents reviewed, the licensee did not comply with the section cited above, as the licensee failed to provide sufficient notice to R1 and R1’s responsible party regarding rate increase, which poses a potential health and safety risk to 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 PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
06/08/2022 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20220608091739

FACILITY NAME:LAND OF ENCHANTMENT 1 BOARD AND CARE LLCFACILITY NUMBER:
565802444
ADMINISTRATOR:ROXANA LARAFACILITY TYPE:
740
ADDRESS:78 W GAINSBOROUGH RDTELEPHONE:
(805) 601-5202
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
05/19/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Markdel Estrada - CaregiverTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not assist resident with self-administered medications as prescribed

Staff are not treating resident's with respect

Staff did not safeguard resident's personal belongings
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
**This is an amended report that updates the findings of one of the allegations on the report that was issued on 10/20/2022**

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent visit to continue the investigation of the allegations listed above. Upon arrival LPA met with Staff Markdel Estrada and explained the reason for the visit. Estrada called Licensee Roxana Lara who stated Markdel can sign for the report.

On 6/9/2022, between 9am - 3pm, LPA conducted the initial 10-day complaint visit. LPA conducted physical plant, reviewed and obtained pertinent documents relevant to the investigation as well as interviewed staff, residents, outside agencies and families of residents in care. Today, LPA conducted physical plant, interviewed staff, responsible parties and conducted medication audit for (4) residents in care.

It was alleged that staff did not assist resident with self-administered medication as prescribed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
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 6
Control Number 29-AS-20220608091739
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: LAND OF ENCHANTMENT 1 BOARD AND CARE LLC
FACILITY NUMBER: 565802444
VISIT DATE: 05/19/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099-A

LPA records review of Resident 1 (R1)'s centrally stored medication list and Medication Administrative Records (MAR) revealed that the two (2) medications specified in the allegation as not administered as prescribed were observed to be administered to R1 as prescribed from 03-01-2022 to present at this time
LPAs record review of four (4) other residents' MAR, revealed each resident was administered their medications as prescribed from 3/1/2022 to present, at this time. On 10/20/2022, at approximately 10am, LPA conducted medication audit of R1, Resident 2 (R2), Resident 3 (R3), Resident 4 (R4) and Resident 5 (R5). LPA's medication audit revealed that each resident appeared to have their medication given as prescribed at this time. LPAs interview with responsible parties of residents in care revealed that most did not express any immediate or potential concerns of medications not being administered as prescribed. Most of the responsible parties interviewed also do not recall ever being notified of any medication not being administered as prescribed. It was also stated that R1's medications were ordered without the consent of R1's responsible party. LPA's interview with optometrist of R1 revealed they do not not keep records of who calls to fill prescription orders at this time. Based on interviews conducted, records review and medication audit, the department does not have sufficient evidence to determine that staff did not assist resident with self administered medication as prescribed. Therefore, the above allegation is deemed UNSUBSTANTIATED at this time.

It was alleged that staff are not treating residents with respect, with specifics on Staff 1 (S1) allegedly pushing R1 in the back and verbally abusing other residents in care. LPAs interview with the responsible parties of the residents in care revealed that most visit the facility at least once a week and most have never witnessed S1 push R1 or any other residents in care whenever they visit. Interview with the responsible parties and Hospice agency staff who visit at least once a week further revealed that they have never witnessed S1 verbally abuse any residents in care and most did not express any potential or immediate concerns for S1 servicing the residents in care at this time. LPAs interview with R1 and R2 , revealed they each have not witnessed any staff physically or verbally abuse residents in care at this time. R1 and R2 also did not express any potential or immediate concerns with S1 servicing them at this time. LPA was not able to interview other (4) residents during LPAs visits at this time. During LPAs (2) visits to the facility, LPA observed S1 and other staff treat residents in care with dignity and respect. Based on interviews conducted, records review, and observations the department does not have sufficient evidence to determine that staff are not treating resident's with respect. Therefore, the above allegation has been deemed UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20220608091739
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: LAND OF ENCHANTMENT 1 BOARD AND CARE LLC
FACILITY NUMBER: 565802444
VISIT DATE: 05/19/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from 9099-C

It was alleged that staff did not safeguard resident's personal belongings as R1s comb was missing. LPAs interview with staff revealed that R1 states there have been times where R1 states they are missing a black comb. Often times Staff have found the black comb in various areas of R1s room. Most recently the black comb was located in a basket in R1's closet. LPA interview with R1 revealed they do not recall missing any of their personal belongings in R1s room and they did not express any potential or immediate concerns of their personal belongings not being safely kept in R1s room. LPAs interview with R2 revealed they have never had any of their personal items go missing and R2 did not express any potential or immediate concerns for any of their personal items go missing due to staff. LPAs interview with responsible parties of the residents in care revealed that most have not witnessed or experienced the personal belongings of their residents in care go missing at this time. The responsible parties also did not express any potential or immediate concerns for the residents' personal belongings not being safeguarded by staff at this time. Based on interviews conducted, the department does not have sufficient evidence to determine that staff did not safeguard resident's personal belongings. Therefore, the above allegation has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted and report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6