565850167-3-22-2023-29-AS-DPEA-CQBTPK-20230327145429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850167
Report Date: 03/22/2023
Date Signed: 03/22/2023 07:35:15 PM

Unsubstantiated

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
05/19/2022 and conducted by Evaluator Zabel Chochian

COMPLAINT CONTROL NUMBER: 29-AS-20220519144248

FACILITY NAME:	CASA BLANCA SENIOR LIVING		FACILITY NUMBER:	565850167
ADMINISTRATOR:	VIGIL, MONICA		FACILITY TYPE:	740
ADDRESS:	5631 EUNICE AVE.		TELEPHONE:	(805) 218-0397
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	4	CENSUS: 3	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Monica Vigil		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident care needs not met

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent visit to deliver investigation finding. LPA met with Licensee/Administrator Monica Vigil and reason for visit was explained.

On 05/19/2022, information was provided that a welfare check for resident #1 (R1) was requested by facility staff on 05/18/2022 at approximately 5:23PM due to resident #1 allegedly making suicidal statements. Staff claimed they overheard R1 say on the phone they wanted to kill self, but no means or specifics were given. R1 denied wanting to harm or kill self. R1 reported being held at the facility against own will. R1 claimed staff refused to take resident on a walk which upset resident. At approximately 7:26PM, law enforcement was dispatched back to facility as a result of R1 leaving the facility. R1 was located at the neighbor’s front yard (5679 Eunice St.). R1 was returned to the facility without incident. Reporting party believes facility is unable to meet R1’s needs with only one staff present.

On May 26, 2022, LPA Martha Guzman-Chavez conducted the initial complaint visit. (continue to LIC9099c)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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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Control Number 29-AS-20220519144248

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: CASA BLANCA SENIOR LIVING	FACILITY NUMBER: 565850167
	VISIT DATE: 03/22/2023

NARRATIVE

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LPA toured the facility, interviewed the Administrator, staff, and R1 between 10:03AM - 10:50AM. LPA also obtained copies of pertinent documents. Records reviewed revealed that R1 was admitted to facility on 04/02/2022 and moved out on 06/01/2022. Physician report dated 03/02/2022 and Resident Appraisal dated 03/30/2022 did not indicate any special needs for supervision as there was no indication of R1 having any wandering or exiting behavior. According to staff and Administrator at the time of the incident (05/18/2022) involving R1, the facility census was two (2) and one staff on duty at the time was sufficient. Administrator and her husband live and work at the facility as well. Interview with Staff, Administrator, and resident revealed the staff provided the care, and supervision to meet the need of both residents in care at the time. Administrator explained that R1 was living at home in a bad environment which resulted in R1 being hospitalized. Administrator stated R1 was fine upon admission to her facility. According to Administrator R1 began exhibiting unusual behavior and they did everything to meet R1’s needs by communicating with R1’s conservator to arranging doctor appointments; R1 was assisted with dressing/grooming, bathing and toileting needs every day. Administrator stated that one staff on duty was sufficient since R2 was self-sufficient in perform all activities of daily living but bathing. Following this one incident which happened on 05/18/2022 Administrator ensured two (2) staff were available at the facility at all times for the safety of R1 and R2 until things subside and/or new placement was found for R1. During todays visit, three out of three resident observed/interviewed at approximately 1pm observed in good spirits; reported that they are happy and well taken care; feel safe at the facility.

Based on the interviews conducted and records reviewed there is insufficient evidence to support allegation. Therefore, allegation "Resident care needs not met" is deemed unsubstantiated at this time.

Exit interview conducted and copy of report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

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