565850357-8-22-2023-29-AS-DPEA-CW3KNF-20230927080304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850357
Report Date: 08/22/2023
Date Signed: 08/22/2023 01:39:23 PM

Substantiated

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
08/18/2023 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20230818130808

FACILITY NAME:	AMERICA'S CARE		FACILITY NUMBER:	565850357
ADMINISTRATOR:	CALLES, MARIA D		FACILITY TYPE:	740
ADDRESS:	5763 KATHERINE ST		TELEPHONE:	(818) 448-8641
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 4	DATE:	08/22/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Maria Calles		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Unlicensed care being provided

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA’s) Martha Arroyo and Emily Peraldi conducted an unannounced visit at the above location at 8:00 a.m. Upon arrival, the LPA’s knocked on the front door and staff #1 (S1) opened the door. At 8:10 a.m., S1 called the Operator, Maria Calles which then advised LPA’s they were on their way. At this time, the LPA’s advised the Operator that Community Care Licensing Division (CCLD) received a complaint regarding unlicensed care being provided at this address.

At 8:16 a.m., the LPAs’ were allowed entry to the property by S1. At 8:30 a.m., the Operator arrived at the property and at 8:32 a.m., the LPA’s conducted a brief physical plant tour to ensure there are no health and safety concerns. The LPA’s observed this location to have six (5) bedrooms, two (2) bathrooms, and six (6) beds. There were four (4) clients observed in this location at the time of visit. Between 8:19 a.m. and 9:00 a.m., the LPA’s conducted interviews with the Operator, one (1) staff, and four (4) clients, and conducted a file review at 8:52 a.m.
(Report Continued on LIC 9099C...)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 3

Control Number 29-AS-20230818130808

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: AMERICA'S CARE	FACILITY NUMBER: 565850357
	VISIT DATE: 08/22/2023

NARRATIVE

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(Report Continued from LIC 9099C...)

It was alleged that unlicensed care is being provided. It was reported that this property had at least two (2) clients that require care and supervision. Record review revealed three (3) out of four (4) clients were relocated to this property from a licensed facility. Additionally, based on the information obtained from interviews and record review, it was revealed that four (4) out four (4) clients require assistance and are being provided elements of care, which include assistance with activities of daily living (ADL’s) such as bathing, dressing, toileting, and medication assistance. Therefore, the allegation of unlicensed care is being provided is deemed Substantiated at this time.

LPAs issued and read the Notice of Operation in Violation of Law (NOVL) with Operator Maria Calles during today’s visit. There is a current pending application for America’s Care # 565850357. The LPAs reminded operator that no residents shall be admitted until the facility is licensed.

Citation was issued per Health and Safety Code (See LIC 9099-D):

Exit interview conducted. Appeal rights and report reviewed with Operator and a copy of the report was issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230818130808

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: AMERICA'S CARE	FACILITY NUMBER: 565850357
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/22/2023 Section Cited HSC 1569.10	1 2 3 4 5 6 7	1569.10. RCFE; license or permit; necessity: No person, firm, partnership, association, or corporation... shall operate, establish, manage, conduct, or maintain a residential facility for the elderly in this state without a current valid license... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Applicant/Operator stated that they shall not admit new residents.
	8 9 10 11 12 13 14	Based on interviews and record review, the Operator did not comply with the section cited above as four (4) out of four (4) clients require supervision and are receiving assistance with aspects of care, which poses an immediate health and safety risk to tenants 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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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