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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609944
Report Date: 10/05/2021
Date Signed: 10/05/2021 11:58:24 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
12/14/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20201214093520
FACILITY NAME:LA VENTANA TREATMENT PROGRAMSFACILITY NUMBER:
567609944
ADMINISTRATOR:KLEIN, DIAHANNFACILITY TYPE:
772
ADDRESS:2479 LA GRANADA DRIVETELEPHONE:
(805) 371-1274
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 6DATE:
10/05/2021
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Steve Zamarripa and Sharon VolnerTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff are not adequately supervising residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst Ashley Smith arrived unannounced to conduct a subsequent complaint visit. The LPA met with Program Director Sam Pow and explained the reason for the visit. The LPA also met with License Steve Zamarripa and Clinial Director Sharon Volner.

During the initial virtual visit conducted on 12/22/2020, the LPA interviewed staff at 3:24pm, 3:33pm, and 3:43pm. During today’s visit, the LPA conducted a tour at 9:50am, and interviewed staff at 9:59am, 10:49am, 10:53am, 11:01am, and 11:09am.

Regarding the above allegation, it was alleged that the facility failed to properly supervise a client. Interviews revealed that clients are unable to leave the community without staff supervision. Interviews confirmed that there was a client whom resided at this facility in December 2020 (C1) and C1 had attempted to leave the facility against treatment advice on approximately 12/08/2020.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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-20201214093520
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: LA VENTANA TREATMENT PROGRAMS
FACILITY NUMBER: 567609944
VISIT DATE: 10/05/2021
NARRATIVE
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Interviews conducted revealed that during the incident on 12/08/2020, C1 was frustrated and left the facility, yet staff stayed with C1 at an appropriate distance. Staff stated that they were within 20 feet of C1. C1 allegedly approached a neighboring home but did not engage with the neighbor and returned to the facility. This incident was also documented in facility notes. Additional interviews and a review of video surveillance confirmed that C1 left the facility on approximately 12/10/2020 in the afternoon. Video surveillance revealed that C1 approached a door and asked for liquor, but was refused. Video surveillance documented C1 at the residence for approximately 60 seconds. During the encounter, there was no staff presence or intervention. There were no facility notes or documentation detailing that this incident transpired, yet video surveillance did not capture staff supervision.

Based on the information obtained, there is sufficient evidence to support the claim that facility staff did not adequately supervise C1. This allegation is deemed Substantiated at this time.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):
Exit interview conducted, today's reports and appeal rights were reviewed and issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20201214093520
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: LA VENTANA TREATMENT PROGRAMS
FACILITY NUMBER: 567609944
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2021
Section Cited
CCR
81078(a)
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81078(a) Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:

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The Licensee agreed to do the following:
The facility will send the policy as it relates to leaving against treatment advice (ATA). Policy to be sent no later than 10/6/2021.
2. The facility will conduct an in-service training regarding the ATA policy.
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Based on interview and video surveillance, the licensee did not comply in the section cited above for one out of six clients (C1), which poses an immediate health and safety risk to clients in care.
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Submit in-service sign-in sheets once training is completed. In service training to be completed within the next 7 days.
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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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3