565802448-7-16-2021-29-AS-DPEA-CB7V8T-20220131151317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802448
Report Date: 07/16/2021
Date Signed: 07/16/2021 04:41:07 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
07/13/2021 and conducted by Evaluator Kasandra Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 29-AS-20210713154125

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:	07/16/2021
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Anna Joy Bautista		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Licensee did not ensure resident was receiving appropriate wound care.
Administrator is trying to get resident relocated to another facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial complaint inspection at the facility today regarding the above allegations. The LPA met with Staff #1 (S1) who contacted the Administrator at 12:44 PM. The LPA spoke with the Administrator and explained the reason for today's inspection.

At 12:45 PM the LPA conducted a physical plant tour with S1. At 12:57 PM the LPA began record review. At 1:17 PM the LPA conducted an interview with R1. At 1:36 PM the LPA conducted an interview with Administrator. At 2:35 PM the LPA reviewed hospice records for R1.

Record reviewe revealed R1 has an order with hospice for would care three times a week. The Administrator stated during her interview, between the hospice physician, nurses and home health aides someone comes to the facility every day and they address her wound care. The interview with R1 revealed hospice comes daily to the facility. 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: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

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-20210713154125

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: 07/16/2021

NARRATIVE

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Hospice record review revealed that an appropriately skilled professional (RN or LVN) from hospice comes to the facility approximately three or four times a week. The physician also conducts weekly wound care progress reports.

Based on the information obtained during the investigation, the allegation of "Licensee did not ensure resident was receiving appropriate wound care" is deemed unsubstantiated at this time.

During the interview with the Administrator, the Administrator denied trying to get R1 relocated to another facility and discussed applying for an exception for R1 if R1's hospice care is terminated in the future. During the interview with R1, they stated they were happy at the facility and has no issues or concerns regarding how staff or the Administrator treats R1. Based on the information obtained during the investigation, the allegation of "Administrator is trying to get resident relocated to another facility" is deemed unsubstantiated at this time.

Report was reviewed and exit interview conducted with the Administrator. A copy of the report and appeal rights will be emailed.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC9099 (FAS) - (06/04)

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