565802448-12-22-2021-29-AS-DPEA-CA6UZA-20211229150113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802448
Report Date: 12/22/2021
Date Signed: 12/22/2021 01:41:25 PM

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
03/12/2021 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20210312145243

FACILITY NAME:	A LOVING CARE VILLA		FACILITY NUMBER:	565802448
ADMINISTRATOR:	BAUTISTA, ANNA JOY		FACILITY TYPE:	740
ADDRESS:	6217 ANASTASIA STREET		TELEPHONE:	(805) 285-0483
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 4	DATE:	12/22/2021
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Albert Salunga & Myline Olivas		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff yelled at resident while in care.
Staff handled resident in a rough manner.
Staff spoke inappropriately to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kasandra Lopez conducted an unannounced subsequent complaint visit to deliver final investigation finding regarding above allegations. During today’s visit LPA Lopez met with Administrator Albert Salunga and Myline Olivas and explained reason for visit.

Following is a summary of the investigation:
On 03/12/2021 the Department received a complaint with the above allegations. It was reported that the staff "holler", yell and tell Resident 1 (R1) “shut-up”. Also, it is alleged that staff held R1’s arms too tight when they provided services.

On 03/22/2021, LPA Chochian conducted the initial complaint visit. Due to the situation surrounding the Corona Virus Disease 2019 (COVID-19), and to implement mitigation measures, the initial complaint investigation was conducted telephonically/virtually with Administrator Joy Bautista between the hours from 2:00 PM. to 5:15 PM. Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

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-20210312145243

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: A LOVING CARE VILLA	FACILITY NUMBER: 565802448
	VISIT DATE: 12/22/2021

NARRATIVE

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Allegations were discussed with administrator and staff. Both administrator and staff denied allegations. Administrator stated that R1 was admitted to the facility on 03/09/2021 and moved out 03/11/2021. Prior to R1 moving into the facility R1 lived at home. Administrator explained that R1 was upset about the move and wanted to return home. R1 exhibit extreme agitation, aggression, emotional and mental unstable behavior. R1’s responsible person was aware of R1’s behavior and eventually R1 returned home.

On 03/22/2021, LPA Chochian conducted a virtual tour of the facility common areas and resident bedrooms. Residents able to communicate with LPA were interviewed privately. Three out five residents interviewed reported feeling safe in the facility and did not report any mistreatment by staff.

LPA made several attempts to contact R1’s responsible person during investigation. No return call was received.

Based on the above, there is not enough evidence to support allegations. Therefore, allegations are deemed Unsubstantiated at this time.

Exit interview and report reviewed with the Administrator. A copy of report was emailed.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021

LIC9099 (FAS) - (06/04)

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