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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850108
Report Date: 02/10/2023
Date Signed: 02/10/2023 12:06:59 PM

Unfounded


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
02/09/2023 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20230209112701
FACILITY NAME:OAK PLACE RESIDENTIAL CAREFACILITY NUMBER:
565850108
ADMINISTRATOR:SPRING, BECKYFACILITY TYPE:
740
ADDRESS:50 OAK ST.TELEPHONE:
(805) 586-4086
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:36CENSUS: 36DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
11:51 AM
MET WITH:Flordeliza "Baby" HipolitoTIME COMPLETED:
12:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect caused a resident to be hospitalized while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 11:51 AM and met with facility designee Flordeliza Hipolito, who is authorized to sign reports. Entrance interview conducted.

During today's visit, LPA interviewed facilty designee and obtained a copy of the facility's resident roster. Interview and review of roster revealed that Resident #1, whom the complaint is in reference to, does not reside at this facility. Based on the information obtained, the allegation is deemed UNFOUNDED at this time. A finding of unfounded means that the allegation is either false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. A copy of the report was provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
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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