565802448-2-3-2022-29-AS-DPEA-CCF2AT-20220311161404

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802448
Report Date: 02/03/2022
Date Signed: 02/03/2022 02:53:28 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
04/14/2021 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20210414151416

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: 3	DATE:	02/03/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Albert Salunga		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff gave resident wrong medications
Staff did not ensure the facility is free from pests
Residents personal property is missing
Facility is malodorous
Facility is out of ratio
Facility food is not of a nutritious quality

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced subsequent complaint visit to deliver final investigation finding regarding above allegations. During today’s visit LPA Chochian met with new administrator Albert Salunga and reason for the visit was explained.

Following is a summary of the investigation findings:
On 04/22/2021, LPA Zabel Chochian initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, initial complaint investigation was conducted telephonically/virtually with former administrator Joy Bautista. Between 3:30pm - 4:30pm LPA toured the facility common areas including resident bedrooms. Residents able to communicate with LPA were interviewed including administrator and staff. Administrator denied ever operating over capacity and all other allegations noted above. Most residents interviewed did not know the census of the facility.However, one out six residents interviewed did confirm that the census of the facility is six. Residents able to communicate with LPA did not report any issues with the allegations listed on this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

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-20210414151416

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: 02/03/2022

NARRATIVE

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Administrator stated that all residents are assisted with their medication as prescribed; they have no reported pest issue; no resident reported anything missing; facility is cleaned daily and kept free from any bad odor; and all residents are provided with a minimum of three nutritious meals a day plus snacks. On 04/22/2021 visit LPA observed six residents and two staff including administrator; LPA also observed facility food supply to be stocked with variety of snacks; fresh and frozen vegetables; variety of fruits and juices; milk; eggs; meats; poultry and fish.

LPA attempt to gather addition information from reporting party however no supporting evidence was provided to support any of the allegations.

Based on the interviews conducted and observation, there is not enough evidence to support allegations. Therefore, allegations are deemed Unsubstantiated at this time. Exit interview held, copy of report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2022

LIC9099 (FAS) - (06/04)

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