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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609849
Report Date: 12/29/2022
Date Signed: 12/29/2022 04:37:23 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
02/26/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210226163050
FACILITY NAME:PCS - FERNWOODFACILITY NUMBER:
567609849
ADMINISTRATOR:DANIEL, DADESIIFACILITY TYPE:
735
ADDRESS:515 FERNWOOD DRTELEPHONE:
(805) 307-1810
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:4CENSUS: 4DATE:
12/29/2022
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Didi Daniel, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff denied a client access to a telephone
Staff denied a client visitations
Staff did not seek medical attention for a client
Staff denied a client access to personal belongings
Staff failed to assist client after multiple falls
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Didi Daniel, Administrator and explained the purpose of the visit.

On the allegation: Staff denied a client access to a telephone. On 3/5/21 starting at 12:12 pm interviews were conducted with staff and client, on 9/14/21 starting at 11:23 am interviews were conducted with staff and clients, on 11/22/22 starting at 9:42 am and 11/28/22 starting at 9:33 am interviews were conducted with staff. Interviews revealed that the facility phone has been broken and clients would not have access to a phone for a day or two. Staff were observed unplugging the phone and telling clients it was broken. A review of C1’s records on 10/24/22 starting at 1:42 pm revealed that on 8/28/21 starting at 3:10 pm C1 wanted to talk to their family member on the phone and was told that the phone did not work. On 8/28/21 starting at 5:40 pm C1 tried to leave through the kitchen window and cried to staff stating that they really wanted to talk to their family member.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
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 7
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
02/26/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20210226163050

FACILITY NAME:PCS - FERNWOODFACILITY NUMBER:
567609849
ADMINISTRATOR:DANIEL, DADESIIFACILITY TYPE:
735
ADDRESS:515 FERNWOOD DRTELEPHONE:
(805) 307-1810
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:4CENSUS: 5DATE:
12/29/2022
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Didi Daniel, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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5
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9
Client was hit while in care
Staff humiliated client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Didi Daniel, Administrator and explained the purpose of the visit.

On the allegation: Client was hit while in care. Concerns were that client #1 (C1) was hit while in care by staff as C1 was slapped in the face by staff. On 3/5/21 starting at 12:12 pm interviews were conducted with staff and client, on 9/14/21 starting at 11:23 am interviews were conducted with staff and clients, on 11/22/22 starting at 9:42 am and 11/28/22 starting at 9:33 am interviews were conducted with staff. Interviews revealed that no one observed C1 being slapped in the face by staff. Staff denied slapping C1 in the face. C1 when interviewed denied being slapped in the face. Based on the information obtained during the investigation, the allegation that client was hit while in care by staff is unsubstantiated at this time.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20210226163050
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: PCS - FERNWOOD
FACILITY NUMBER: 567609849
VISIT DATE: 12/29/2022
NARRATIVE
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On the allegation: Staff humiliated client. Concerns were that staff humiliated client as staff laughed at C1 when they fell in the shower. On 3/5/21 starting at 12:12 pm interviews were conducted with staff and client, on 9/14/21 starting at 11:23 am interviews were conducted with staff and clients, on 11/22/22 starting at 9:42 am and 11/28/22 starting at 9:33 am interviews were conducted with staff. Interviews revealed that that no one observed staff laughing at C1 when they fell in the shower. Staff denied laughing at C1 when they fell. C1 when interviewed denied staff laughing at them when they fell. Based on the information obtained during the investigation, the allegation that staff humiliated client is unsubstantiated at this time.

Exit interview conducted, a copy of the report was emailed to the Administrator
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 29-AS-20210226163050
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: PCS - FERNWOOD
FACILITY NUMBER: 567609849
VISIT DATE: 12/29/2022
NARRATIVE
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On 3/5/21 starting at 12:12 pm interviews were conducted with staff and client, on 9/14/21 starting at 11:23 am interviews were conducted with staff and clients, on 11/22/22 starting at 9:42 am and 11/28/22 starting at 9:33 am interviews were conducted with staff. Interviews revealed that C1’s tv and radio were taken away by staff because they were throwing them. C1’s tv, shoelaces, scarves were also taken away by staff when C1 would exhibit suicidal behaviors. C1 when interviewed stated that when they get in trouble staff take away their teddy bear and roses. Based on the information obtained during the investigation, the allegation that staff denied a client access to personal belongings is substantiated at this time.

On the allegation: Staff failed to assist client after multiple falls. On 3/5/21 starting at 12:12 pm interviews were conducted with staff and client, on 9/14/21 starting at 11:23 am interviews were conducted with staff and clients, on 11/22/22 starting at 9:42 am and 11/28/22 starting at 9:33 am interviews were conducted with staff. Interviews revealed that when C1 has fallen staff has yelled at C1 to get up by themselves. Staff would give C1 a chair to help themselves up off the floor as C1 was too heavy for staff to lift up. C1 when interviewed stated that staff will not help them up when they fall. A review of C1’s records on 11/15/22 starting at 3:38 pm revealed that on 1/26/21 C1 fell on the floor and after 5 prompts from staff C1 got up. On 2/13/21 C1 stumbled and fell, staff got C1 a chair so C1 could pull themselves up. On 2/28/21 C1 fell staff got C1 a chair so C1 could get up. On 8/24/21 C1 fell, hit their head, was confused and dizzy and couldn’t get up. C1 laid on the floor for about 45 minutes before getting up to go to the couch. On 8/24/21 C1 was falling all over holding onto the couches, walking in circles tripped and fell on the floor and laid there for 10 minutes then got up. On 8/26/21 C1 fell in the shower. Staff helped C1 with the shower chair for support. It took C1 about 30 minutes to get off the floor. Based on the information obtained during the investigation, the allegation that staff failed to assist C1 after multiple falls is substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

Exit interview was conducted, today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20210226163050
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: PCS - FERNWOOD
FACILITY NUMBER: 567609849
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2022
Section Cited
CCR
85072(b)(9)
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85072(b)(9) Personal Rights To have access to telephones in order to make and receive confidential calls, provided that such calls do not infringe upon the rights of other clients and do not restrict availability of the telephone during emergencies.
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Administrator agreed to hold training with all staff outlining personal rights, and will submit proof by 12/30/22.
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Based on interview, the licensee did not comply with the above cited section when C1 could not make phone calls, which posed a potential personal rights risk to residents in care.
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Type B
12/30/2022
Section Cited
CCR
85072(b)(6)
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85072(b)(6) Personal Rights To possess and use his/her own personal items, including his/her own toilet articles.
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Administrator agreed to hold training with all staff outlining personal rights, and will submit proof by 12/30/22.
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Based on interview, the licensee did not comply with the above cited section when staff took away C1’s personal items, which posed a potential personal rights risk to residents 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: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20210226163050
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: PCS - FERNWOOD
FACILITY NUMBER: 567609849
VISIT DATE: 12/29/2022
NARRATIVE
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 Based on the information obtained during the investigation, the allegation that staff denied a client access to a telephone is substantiated at this time.

On the allegation: Staff denied a client visitations. The concern was staff denied C1 private visits with family members. On 3/5/21 starting at 12:12 pm interviews were conducted with staff and client, on 9/14/21 starting at 11:23 am interviews were conducted with staff and clients, on 11/22/22 starting at 9:42 am and 11/28/22 starting at 9:33 am interviews were conducted with staff. Interviews revealed that C1’s family member asked staff to close the blinds and the doors while C1 visited with them outside. Staff refused to close the blinds and told C1’s family member that they need to see C1 to supervise them during the visit. A review of C1’s records on 11/15/22 starting at 3:38 pm revealed that on 2/13/21 C1’s family member requested staff to go inside and leave them alone with C1 because they went to visit C1 and it is their personal time. Staff let C1’s family member know that they could go inside but they need to be able to see C1 in case they needed assistance. Based on the information obtained during the investigation, the allegation that staff denied a client private visitation is substantiated at this time.

On the allegation: Staff did not seek medical attention for a client. The concern was staff did not seek medication attention when C1 was dizzy, weak and vomited after receiving their COVID vaccines on 1/7/21 and 2/4/21. On 3/5/21 starting at 12:12 pm interviews were conducted with staff and client, on 9/14/21 starting at 11:23 am interviews were conducted with staff and clients, on 11/22/22 starting at 9:42 am and 11/28/22 starting at 9:33 am interviews were conducted with staff. Interviews revealed that C1 was sick after their COVID vaccine and requested to go to the doctor. C1 when interviewed stated that the COVID vaccines made them really sick and they requested to go to the doctor and staff did not take them. Interview with Administrator revealed that they notified C1’s primary care provider by telephone however, C1 was not taken to the doctor or hospital. A review of C1’s records on 10/24/22 starting at 1:42 pm revealed that on 1/8/21 C1 did not finish their lunch stating that they were dizzy, weak and had to vomit. C1 laid back in bed but still was not feeling well. Staff assisted C1 to the restroom and C1 vomited. Based on the information obtained during the investigation, the allegation that staff did not seek medical attention for a client is substantiated at this time.

On the allegation: Staff denied a client access to personal belongings. Concerns were that staff would punish C1 by taking away C1’s stuffed animals.
Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20210226163050
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: PCS - FERNWOOD
FACILITY NUMBER: 567609849
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2022
Section Cited
CCR
80075(a)
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80075(a) Health Related Services The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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Administrator agreed to submit a written statement of understanding of 80075(a) and will train staff about the requirement to seek timely medical attention for clients. Will submit statement and training by 12/30/22.
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This requirement was not met as evidenced by:
Based on interview, the licensee did not comply with the above cited section when C1 requested medical attention and staff did not arrange it, which posed an immediate health and safety risk to residents in care.
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Type A
12/30/2022
Section Cited
CCR
80078(a)
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80078(a) Responsibility for Providing Care and Supervision The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Administrator agreed to hold training with all staff outlining personal rights and meeting client’s needs, and will submit proof by 12/30/22.
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Based on interview and record review, the licensee did not comply with the above cited section when staff did not assist C1 up after C1 fell, which posed an immediate health, safety, and personal rights risk to residents 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: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7