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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802448
Report Date: 12/22/2021
Date Signed: 12/28/2021 05:21:43 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
03/11/2020 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 31-AS-20200311163039
FACILITY NAME:A LOVING CARE VILLAFACILITY NUMBER:
565802448
ADMINISTRATOR:BAUTISTA, ANNA JOYFACILITY TYPE:
740
ADDRESS:6217 ANASTASIA STREETTELEPHONE:
(805) 210-5356
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 4DATE:
12/22/2021
UNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Albert Salunga and Myline OlivasTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff failed to meet residents' needs
facility staff failed to provide residents adequate meals
Facility staff failed to safeguard resident's personal belongings
Facility staff threatened residents with eviction
Facility staff failed to assist residents in a timely manner
Activities are not offered
Facility staff chemically restrained resident
Facility staff failed to provide resident with privacy.
INVESTIGATION FINDINGS:
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This report is being amended to add missing information regarding allegation "Facility staff threatened residents with eviction" (see 9099C lines 15-19) No change in the finding.

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 ans Myline Olivas and explained reason for visit.

Following is a summary of the investigation: On 03/20/2020, 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 with Administrator Joy Bautista between the hours from 4:15 p.m. to 5:30 p.m. Allegations above were discussed. Administrator stated that all residents are kept clean and made comfortable; all staff respect residents’ privacy; provided residents minimum of three meals a day plus snacks. Report continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (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)
Page: 1 of 2
Control Number 31-AS-20200311163039
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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Regarding safeguarding resident personal belongings, administrator stated that residents are provided with a form upon admission to list all personal belongings; residents’ belongings are kept with resident in their respectful room. According to administrator and staff, R1 did make accusations that facility staff are stealing things however nothing was accounted for; R1 declined to itemize personal belongings on the form provided upon admission. No other residents have reported anything missing/stolen.

On 3/26/2020, during a technical assistance virtual visit LPA attempt to interview residents of the facility. Resident 1 (R1) said hello to LPA but declined interview. Other three residents agreed to speak to LPA. Although all three residents had difficulty understanding and responding to majority of the questions, residents did express feeling safe when asked. Residents observed in clean clothing and in good spirts. LPA observed a bell in each residents’ room. Administrator explained the bell is given to each resident for use to alerting staff. However, due to the residents being cognitively impaired and incontinent, staff check on residents every 2 hours.

Regarding allegation "Facility staff threatened residents with eviction" - Staff interviewed stated that no one threatened any resident with eviction. Interview with staff and records review revealed that R1 was issued a valid eviction for non-payment of rent. R1 declined to interview with LPA on any of the allegations. Other residents interviewed did not have any concern with eviction issues, Residents did express feeling safe by saying they are treated well by facility staff, .

LPA asked about the facility activities offered and administrator stated that residents like to listen to music, watch movies, and sometimes play cards/board games. Administrator denied that her staff would chemically restrain any resident. Staff also denied ever chemically restraining any resident. LPA observed all four residents awake during the initial and technical assistance virtual visits.

LPA attempt to contact reporting party and R1 on 03/19/2020; 03/20/2020 and 03/26/2020. Furthermore, LPA made several other attempts to contact reporting party and R1 during the investigation and 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 the report was emailed.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (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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