565850416-8-13-2026-29-AS-DPEA-DXCRQA-20260827131314

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565850416
Report Date: 08/13/2026
Date Signed: 08/13/2026 10:45:21 AM

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
08/29/2025 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20250829140205

FACILITY NAME:	MARICAR'S MANOR II		FACILITY NUMBER:	565850416
ADMINISTRATOR:	AMBER WINTERSTEIN		FACILITY TYPE:	740
ADDRESS:	1168 ARCANE STREET		TELEPHONE:	(805) 210-2480
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 5	DATE:	08/13/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Geraldine Dazo		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are “double diapering” resident

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver final findings of the allegations listed above. Upon arrival LPA met with staff and explained the reason for the visit. LPA contacted Administrator who stated they were unable to be onsite for the visit at this time.

On 09/05/2025, LPA conducted an initial 10-day complaint visit to investigate the allegations listed above. At approximately 09:40 a.m. LPA conducted physical plant tour, interviewed staff, as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 10/17/2025, LPA conducted a subsequent complaint visit to continue investigation on the allegations listed above. At approx. 09:30 a.m. LPA conducted physical plant tour, interviewed staff, residents, families / responsible parties as well as reviewed and obtained additional copies of pertinent documentation relevant to the investigation. On 07/28/2026, hospital records were obtained and reviewed.
It was reported that “Staff were double diapering R1” as it was alleged that R1 was observed wearing two (2) diapers at the same time.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026

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 6

Control Number 29-AS-20250829140205

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: MARICAR'S MANOR II	FACILITY NUMBER: 565850416
	VISIT DATE: 08/13/2026

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

Records reviewed revealed that upon R1's admission to the local Hospital on 08/29/2025, hospital staff documented that R1 arrived wearing two (2) diapers with an absorbent pad. The Administrator stated that R1 was experiencing excessive bleeding and frequent bowel movements. Facility staff do not typically place residents in two diapers but did so for R1 due to repeated leakage throughout the day. Interviews with five (5) staff members indicated they do not routinely place residents in (2) diapers at the same time. Interviews with four (4) residents' family members or responsible parties revealed no concerns regarding residents wearing two (2) diapers. The home health nurse, who visited R1 at least twice weekly, reported no concerns related to residents wearing (2) diapers. R1 stated they had worn (2) diapers on multiple occasions but could not identify specific dates or times. LPA was unable to obtain reliable statements from other residents regarding this allegation. Based on the information obtained during the investigation, the Department has sufficient evidence to confirm this allegation occurred. Therefore the allegation "Staff are "double diapering" resident is Substantiated at this time.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Staff was informed that failure to correct the deficiency may result in civil penalties.

Exit interview conducted with staff, appeal rights discussed and a copy of this report and appeal rights were provided

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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
08/29/2025 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20250829140205

FACILITY NAME:	MARICAR'S MANOR II		FACILITY NUMBER:	565850416
ADMINISTRATOR:	AMBER WINTERSTEIN		FACILITY TYPE:	740
ADDRESS:	1168 ARCANE STREET		TELEPHONE:	(805) 210-2480
CITY:	SIMI VALLEY	STATE:CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 5	DATE:	08/13/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Geraldine Dazo		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff left resident in soiled diapers for an extended period of time

Staff are not rotating resident every 2 hours resulting in pressure injuries

Staff took away residents pillow

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver final findings of the allegations listed above. Upon arrival LPA met with staff and explained the reason for the visit. LPA contacted Administrator who stated they were unable to be onsite for the visit at this time.
On 09/05/2025, LPA conducted an initial 10-day complaint visit to investigate the allegations listed above. At approximately 09:40 a.m. LPA conducted physical plant tour, interviewed staff, as well as reviewed and obtained copies of pertinent documentation relevant to the investigation. On 10/17/2025, LPA conducted a subsequent complaint visit to continue investigation on the allegations listed above. At approx. 09:30 a.m. LPA conducted physical plant tour, interviewed staff, residents, families / responsible parties as well as reviewed and obtained additional copies of pertinent documentation relevant to the investigation. On 07/28/2026, hospital records were obtained and reviewed.

It was reported that "Staff left resident in soiled diapers for an extended period of time" as It was alleged that staff left R1 in soiled briefs/diapers for extended periods, reportedly up to 14 hours.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 29-AS-20250829140205

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: MARICAR'S MANOR II	FACILITY NUMBER: 565850416
	VISIT DATE: 08/13/2026

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

Interviews with five (5) staff members indicated residents were checked before and after meals, at least hourly, before bedtime, upon request, and as needed during the night shift. Interviews with four (4) family members or responsible parties revealed no concerns regarding residents remaining in soiled briefs/diapers for extended periods. The home health nurse, who visited R1 at least twice weekly, also reported no concerns related to residents being left in soiled briefs/diapers for extended periods. LPA’s interview with R1 revealed they were left in soiled diapers on multiple occasions but could not identify specific dates, times, or the reported duration. LPA was unable to obtain reliable statements from other residents regarding this allegation. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff left resident in soiled diapers for an extended period of time” is deemed Unsubstantiated at this time.

It was reported that "Staff are not rotating resident every 2 hours resulting in pressure injuries" as it was alleged that staff failed to assist R1 with mobilizing around the facility, resulting in pressure injuries to R1's heels. Records reviewed showed R1 was not admitted to the local hospital with wounds on their heels. The home health nurse, who visited R1 at least twice weekly, stated they did not recall R1 having heel wounds while receiving services at this time. LPA's interview with R1 revealed that R1 stated they had heel wounds while residing at the facility but that the wounds healed before they left. R1 could not recall when the wounds occurred. R1 also stated staff did not assist with walking or mobilizing around the facility or outside but could not identify specific dates or times. R1's records indicated R1 required assistance with transferring, bathing, dressing, and toileting. The records did not indicate a need for any repositioning every two (2) hours. Interviews with five (5) staff members revealed that staff made multiple attempts to encourage R1 to mobilize, and R1 often agreed after repeated encouragement, each staff interviewed do not recall R1 leaving to the hospital with any wounds on their heels. Interviews with four (4) family members or responsible parties revealed no concerns regarding the care provided to residents. LPA was unable to obtain reliable statements from other residents regarding this allegation. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff are not rotating resident every 2 hours resulting in pressure injuries” is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 29-AS-20250829140205

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: MARICAR'S MANOR II	FACILITY NUMBER: 565850416
	VISIT DATE: 08/13/2026

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

Continued from 9099-C

It was reported that "Staff took away residents pillows" as It was alleged that staff took R1's pillows. LPA's interview with R1 revealed that upon admission, staff placed pillows under their legs for comfort. It was alleged that after R1's leg cast was removed, staff stopped using the pillows and told R1 they no longer needed them. R1 could not recall specific dates or times and stated they did not ask staff to return the pillows. Interviews with five (5) staff members revealed that they all denied taking pillows from R1 and provided R1 pillows upon request. Staff reported that R1 never complained to them about missing pillows. Interviews with four (4) family members or responsible parties revealed no concerns regarding staff taking residents' personal belongings. LPA was unable to obtain reliable statements from other residents regarding this allegation. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff took away residents pillow” is deemed Unsubstantiated at this time.

Exit interview conducted and report provided to staff.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 29-AS-20250829140205

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: MARICAR'S MANOR II	FACILITY NUMBER: 565850416
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/13/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/21/2026 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee rep agreed to review section cited and provide a letter of understanding and a written plan to ensure future compliance then send to LPA by COB 08/21/2026.
	8 9 10 11 12 13 14	Based on records review and interviews, the licensee did not comply with the above cited section as R1 was observed wearing 2 diapers, which posed a potential health, safety and personal rights 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: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 6