565802444-6-9-2022-29-AS-DPEA-CSBPBF-20230530111014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802444
Report Date: 06/09/2022
Date Signed: 06/09/2022 02:44:35 PM

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
06/08/2022 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20220608091739

FACILITY NAME:	LAND OF ENCHANTMENT 1 BOARD AND CARE LLC		FACILITY NUMBER:	565802444
ADMINISTRATOR:	ROXANA LARA		FACILITY TYPE:	740
ADDRESS:	78 W GAINSBOROUGH RD		TELEPHONE:	(805) 601-5202
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	06/09/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Roxana Lara		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are not following masking protocols to prevent the spread of COVID-19

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced complaint investigation for the above allegations. LPA met with Administrator Roxana Lara and explained the reason for the visit.

Between 9:30am - 3pm, LPA conducted physical plant, interviewed residents, staff, home health providers and resident family members as well as reviewed and obtained pertinent documents relevant to the investigation.

Regarding allegation that staff are not following masking protocols to prevent the spread of COVID-19. During the time of visit, LPA observed all staff wearing masks while servicing residents and while doing miscellaneous tasks around the facility. LPA interview with (3) residents revealed that most residents have observed staff wearing masks throughout the day and while servicing residents.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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-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: 06/09/2022

NARRATIVE

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Continued from 9099

LPA interviews with family members and home health providers further revealed that when they have visited the facility they have observed all staff wearing masks throughout their visit and while servicing residents. Based on information gathered during this visit. The department does not have sufficient evidence to support the allegation the staff are not following masking protocols to prevent the spread of COVID-19, therefore this allegation has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted, report issued and sent via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022

LIC9099 (FAS) - (06/04)

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