565850416-11-18-2024-29-AS-KLOZ-DBE8L6-20241126213612

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850416
Report Date: 11/18/2024
Date Signed: 11/18/2024 02:37:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/20/2024 and conducted by Evaluator Erica Mosley

COMPLAINT CONTROL NUMBER: 29-AS-20240820100505

FACILITY NAME:	MARICAR'S MANOR II		FACILITY NUMBER:	565850416
ADMINISTRATOR:	MARTNEZ, TINA MARIE		FACILITY TYPE:	740
ADDRESS:	1168 ARCANE STREET		TELEPHONE:	(805) 210-2480
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 3	DATE:	11/18/2024
		UNANNOUNCED	TIME BEGAN:	01:43 PM
MET WITH:	Marica Lee - Licensee Representee		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff punch resident.
Resident fell due to lack of supervision.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Erica Mosley conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. The initial visit was conducted on 08/26/2024 by LPAs E. Mosley and M. Arroyo. On today's visit at 1:43p.m., LPA Mosley met with Licensee Representee,Marica Lee and Administrator Calixto Calixtro. Entrance interview.
On 08/26/2024, the Department received a complaint regarding the following allegations, Facility staff punched resident and Resident fell due to lack of supervision.During the initial visit on 08/26/2024, LPA Mosley conducted a plant tour at 10:10 a.m. conducted interviews with the Administrator, four (4) staff, and three (3) residents between 10:01 a.m. and 2:15 p.m., conducted a file review at 10:45 a.m., and obtained copies of pertinent documents relevant to the investigation. LPA toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations.
Report Continued on LIC 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

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-20240820100505

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARICAR'S MANOR II	FACILITY NUMBER: 565850416
	VISIT DATE: 11/18/2024

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

(2ND PAGE) Report Continued from LIC 9099...

On 09/16/2024 telephonic interviews with four (4) family members of residents from 1:35 p.m. to 4:45 p.m. residing at the facility and on 09/16/2024 reviewed relevant documents pertaining to the investigation.

On the allegation, Facility staff punched resident, it is the concern of the Reporting Party (RP) that the facility Staff #1 (S1), Staff #2 (S2) and Staff #3 (S3) punched Resident #1 (R1) all over the body leaving bruises. R1 reportedly had a bruise on their right shoulder but stated it was unrelated to being punched by staff and was due to a fall. RP reported a full body check was conducted on R1 and R1 had a yellow bruise on the right shoulder only and no bruising on the back. Interviews with residents revealed that facility staff have never been physically aggressive including being punched by staff. Residents stated they have never witnessed or aware of staff being physical including punching any residents including R1. Furthermore, residents denied facility staff being rough or aggressive with them at any time while living at the facility. The LPA was unable to interview R1 as they are no longer living at the facility and their current location is unknown. Interviews with staff including S1, S2, and S3 revealed that staff are unaware of any facility staff punching R1 or ever being physically aggressive towards residents. S1, S2, and S3 deny punching R1. Record review reveal that S1, S2, and S3 have not had any disciplinary action or concerns regarding the quality of care they provide. Interviews with resident families revealed that they visit the facility randomly, unannounced ranging one (1) to four (4) times a week with no concerns with the facility staff including S1, S2, and S3. Families have no concerns with the quality of care the facility provides. They have not witnessed any aggressive behavior including punching by any of the staff. Based on information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Facility staff punched resident is deemed unsubstantiated at this time.

Report Continued on LIC 9099C 3RD PAGE...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20240820100505

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARICAR'S MANOR II	FACILITY NUMBER: 565850416
	VISIT DATE: 11/18/2024

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

( 3RD PAGE) Report Continued from LIC 9099C 2ND PAGE...

On the allegation, Resident fell due to lack of supervision, it is the concern of the Reporting Party (RP) that Resident #1 (R1) fell due to lack of supervision. R1 stated that they have a bruise on their right shoulder due to the fall off of their bed of which staff did not assist R1 with afterwards. RP reported a full body check was conducted on R1 and R1 had a yellow bruise on the right shoulder. Staff interviews revealed that there are always two (2) staff regularly scheduled and record review corroborated that the facility has two (2) staff regularly scheduled. Staff interviewed stated they check on residents frequently and have not had any recent falls that they witnessed or made aware of. Staff stated they are unaware that R1 had any falls while residing at the facility. Resident interviews revealed that two (2) staff are regularly scheduled. Staff are attentive and regularly engaged. Residents have not witnessed or heard of any resident falling recently. Residents did not witness R1 fall and were not made aware of R1 falling. Residents reported no concerns with the supervision the facility provides. Interviews with resident families revealed that they visit the facility randomly, unannounced ranging one (1) to four (4) times a week and the facility always has two (2) staff scheduled. Families were not aware or made aware of any recent falls at the facility. Families state that staff are regularly engaged with the residents and have no concerns with the supervision that is provided at the facility. Although the allegation may have happened or is valid, there is insufficient evidence to support the allegation. Therefore, the allegation of Resident fell due to lack of supervision is deemed unsubstantiated at this time.

Exit interview conducted. Report was reviewed and a copy was provided.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3