<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850217
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:52:35 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
12/12/2022 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20221212114622
FACILITY NAME:WE CARE SENIOR FACILITY LLCFACILITY NUMBER:
565850217
ADMINISTRATOR:HORDAGODA, SHASHIKAFACILITY TYPE:
740
ADDRESS:3350 EL NIDO STTELEPHONE:
(818) 571-1905
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 5DATE:
02/02/2023
UNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Shasika HordagodaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facilty is understaffed
Resident's incontinence needs are not being met
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 12:07PM and initially met with Facility Staff Sumanawath Fonseka. Licensee was contacted and arrived at the facility at 12:10PM. Entrance interview conducted.

During today's visit, LPA toured the facility at 12:39PM, interviewed Licensee at 01:12PM, staff between 01:32PM and 01:51PM, residents between 02:28PM to 03:22PM. During an initial visit conducted on 12/13/2022, LPA toured the facility with staff at 11:15AM, interviewed the Licensee telephonically at 11:17AM, interviewed staff at 11:27AM, and LPA reviewed and obtained copies of pertinent documents. Throughout the course of the investigation, LPA reviewed documents. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

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

DATE: 02/02/2023
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 5
Control Number 29-AS-20221212114622
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: WE CARE SENIOR FACILITY LLC
FACILITY NUMBER: 565850217
VISIT DATE: 02/02/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation "facility is understaffed:"
At the time the complaint was received, the facility had 4 residents in total, and recently the facility census increased to 5. Interview revealed that none of the residents require a 2-person assist and most residents require little assistance with their care needs. During the daytime hours, there are typically 2 staff working with the residents, however at night, there is one staff present in the facility. Resident interviews revealed that residents feel their care needs are being met and staffing is sufficient. Based on interview, there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "facility is understaffed" is deemed UNSUBSTANTIATED at this time.

Regarding the allegation "Resident's incontinence needs are not being met:"
Record review revealed that according to the physician's report, R1 is able to care for their own toileting needs. Interview revealed that R1 is not incontinent, but does have occasional accidents. R1 does not use the restroom often, but is able to ambulate to the restroom and use the restroom independently. Interview revealed that R1 waits until they really have to go, then attempts to quickly get to the restroom or that R1 gets busy watching television and forgets to go to the restroom until the need is imminent. R1 does wear incontinence briefs due to the occasional accident, but R1 is not incontinent. At the time of the complaint, R1 had been diagnosed with a UTI, which may have been a factor in R1's needs at that time. Interview revealed that residents feel their needs are being met and that staff are good and helpful. Based on interview and record review, although the allegation may be valid, at this time there is insufficient evidence to support the allegation or that a violation occurred, therefore, the allegation "resident's incontinence needs are not being met" is deemed UNSUBSTANTIATED at this time.

No citations issued with regard to these allegations. Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

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

DATE: 02/02/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
12/12/2022 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20221212114622

FACILITY NAME:WE CARE SENIOR FACILITY LLCFACILITY NUMBER:
565850217
ADMINISTRATOR:HORDAGODA, SHASHIKAFACILITY TYPE:
740
ADDRESS:3350 EL NIDO STTELEPHONE:
(818) 571-1905
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 5DATE:
02/02/2023
UNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Shasika HordagodaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not properly trained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kelly Dulek conducted a subsequent complaint investigation for the allegations listed above. LPA arrived at the facility at 12:07PM and initially met with Facility Staff Sumanawath Fonseka. Licensee was contacted and arrived at the facility at 12:10PM. Entrance interview conducted.

During today's visit, LPA toured the facility at 12:39PM, interviewed Licensee at 01:12PM, staff between 01:32PM and 01:51PM, residents between 02:58PM to 3:22PM. During an initial visit conducted on 12/13/2022, LPA toured the facility with staff at 11:15AM, interviewed the Licensee telephonically at 11:17AM, interviewed staff at 11:27AM, and LPA reviewed and obtained copies of pertinent documents. Throughout the course of the investigation, LPA reviewed documents. The following was then determined:

Report Continued on LIC 9099-
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

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

DATE: 02/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20221212114622
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: WE CARE SENIOR FACILITY LLC
FACILITY NUMBER: 565850217
VISIT DATE: 02/02/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the allegation "Facility staff are not properly trained:"
The allegation refers to staff not having received training on using Resident #1 (R1)'s Hoyer lift. Interview revealed that 2 of 3 staff have been trained on using R1's Hoyer lift. Staff #1 (S1) has not yet received training on use of R1's Hoyer lift.. S1 indicated they do not typically work alone at the facility, however they have at various times. Although interview revealed that the other staff have been trained on utilizing the Hoyer lift on 09/15/2022, there was no documentation of the training. Based on interview and record review, the allegation that "facility staff are not properly trained" is deemed SUBSTANTIATED at this time.

The following deficiency was observed (See LIC 9099-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

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

DATE: 02/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20221212114622
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: WE CARE SENIOR FACILITY LLC
FACILITY NUMBER: 565850217
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/16/2023
Section Cited
CCR
87411(d)(3)
1
2
3
4
5
6
7
87411 Personnel Requirements - General (d) (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to provide training to S1 on use of the Hoyer lift and to provide documentation of all staff training on use of the Hoyer llift to CCL by POC due date.
8
9
10
11
12
13
14
Based on interview and record review, the Licensee did not comply with the above cited section, as training was not provided to S1 and there was no documentation of training provided to any staff on use of a Hoyer lift, which poses a potential safety risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

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

DATE: 02/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5