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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609739
Report Date: 01/27/2023
Date Signed: 01/27/2023 04:02:55 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
01/10/2022 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20220110161554
FACILITY NAME:BIC BRAIN INJURY HOME AT BANNER AVENUEFACILITY NUMBER:
567609739
ADMINISTRATOR:VERONICA L ZEPEDAFACILITY TYPE:
735
ADDRESS:50 BANNER AVETELEPHONE:
(805) 561-9506
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:6CENSUS: 5DATE:
01/27/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:David CervantesTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff served cold oatmeal to resident
Staff are using baby monitors
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted a subsequent complaint visit to deliver findings for the above allegations which were investigated by LPA JoAnn Rosales. LPA met with Co-Administrator David Cervantes and explained the reason for the visit.

Concerns were that staff served cold oatmeal to Resident #1 (R1). On 1/12/22 starting at 2:02 pm interviews were conducted with staff and residents, on 1/4/23 starting at 4:08 pm and interview was conducted with staff. Interviews revealed that Resident 2 (R2) and Resident 3 (R3) were also served cold oatmeal and when it was brought to the attention of the staff it was heated up for them. Based on the information obtained during the investigation, the allegation that staff served cold oatmeal to resident is substantiated at this time.

Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
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 4
Control Number 29-AS-20220110161554
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: BIC BRAIN INJURY HOME AT BANNER AVENUE
FACILITY NUMBER: 567609739
VISIT DATE: 01/27/2023
NARRATIVE
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Concerns were that staff are using baby monitors. On 1/12/22 starting at 2:02 pm interviews were conducted with staff and residents. On 1/4/23 starting at 4:08 pm an interview was conducted with staff. Interviews revealed that there are baby monitors in R2’s and R3’s bedrooms that are being used to hear R2 and R3 when they call out for help. During a facility tour on 1/12/22 starting at 12:11 pm, LPA observed baby monitors which were turned on in R2’s and R3’s bedrooms. LPA observed the 2 baby monitors labeled with R2 and R3’s names on the kitchen island counter. Based on the information obtained during the investigation, the allegation that staff are using baby monitors is substantiated at this time.

During today's visit, LPA discussed the plan of correction with Administrator Lily Zepeda, and Assistant Administrators David Cervantes and Anna Gendron. Staff stated they have tried alternative methods but the baby monitors are the only thing that picks up R2 & R3's calls for assistance and they will be submitted another exception request for the use of baby monitors.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D):

Exit interview was conducted, today's reports and appeal rights reviewed and a copy of provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20220110161554
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: BIC BRAIN INJURY HOME AT BANNER AVENUE
FACILITY NUMBER: 567609739
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2023
Section Cited
CCR
80072(a)(1)
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80072(a)(1) Personal Rights. To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement is not met evidenced by:
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The administrator will submit an exception request for R2 &R3 by 02/06/2023.

And they will also submit proof staff have received training regarding resident rights and serving meals at the appropriate temperature by 02/06/2023.
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Based on LPA’s observations and interviews, the licensee did not comply with the section cited above as staff served residents cold oatmeal and baby monitors were in R2 and R3’s bedrooms so staff can monitor them which poses a potential personal rights risk to persons in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
01/10/2022 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20220110161554

FACILITY NAME:BIC BRAIN INJURY HOME AT BANNER AVENUEFACILITY NUMBER:
567609739
ADMINISTRATOR:VERONICA L ZEPEDAFACILITY TYPE:
735
ADDRESS:50 BANNER AVETELEPHONE:
(805) 561-9506
CITY:VENTURASTATE: CAZIP CODE:
93004
CAPACITY:6CENSUS: 5DATE:
01/27/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:David CervantesTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff retaliated against resident #1 (R1) for making a complaint.

INVESTIGATION FINDINGS:
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Concerns were that staff retaliated against R1. On 1/12/22 starting at 11:07 am interviews were conducted with staff and residents. On 1/4/23 starting at 4:08 pm an interview was conducted with staff. Interviews revealed that staff denied retaliating against any residents for making a complaint. Interviews with residents revealed that residents denied staff retaliating against them for making a complaint. R1 when interviewed denied being retaliated against.

Based on the information obtained during the investigation, the allegation that staff retaliated against resident for making a complaint is unsubstantiated at this time.
Exit interview was conducted, today's reports and appeal rights reviewed and a copy was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
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 4