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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609944
Report Date: 12/13/2021
Date Signed: 12/13/2021 02:56:52 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
11/13/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20201113113519
FACILITY NAME:LA VENTANA TREATMENT PROGRAMSFACILITY NUMBER:
567609944
ADMINISTRATOR:KLEIN, DIAHANNFACILITY TYPE:
772
ADDRESS:2479 LA GRANADA DRIVETELEPHONE:
(818) 584-5615
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 3DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Rebekah Sanchez NortonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility operating over capacity
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA initially met with Clinical Director Rebekah Sanchez Norton and explained the reason for the visit. Shortly thereafter, the LPA met with License Steve Zamarripa and Chief Clinical Officer Sharon Volner.

During the initial virtual visit on 11/17/2020, LPA Smith and LPA KaSandra Lopez conducted a virtual tour at 10:40 a.m. and requested documents. During the visit conducted on 10/5/2021, the LPA conducted a tour at 9:50am, conducted a medication audit from 10:05 a.m. – 10:40 a.m., and interviewed staff at 9:59am, 10:49am, 10:53am, 11:01am, and 11:09am. During today’s visit, the LPA interviewed staff from 12:20 p.m. – 12:50 p.m., and obtained documents.


CONT 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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 5
Control Number 29-AS-20201113113519
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: 12/13/2021
NARRATIVE
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Regarding the allegation: Facility operating over capacity.

It was alleged that during the months of September 2020 – November 2020, this facility housed up to seven (7) clients, yet the facility is only licensed for six (6) clients. Interviews and records review confirmed that at least on one (1) occasion, this facility had an additional client residing at the facility on 11/10/2020. Interviews stated that whereas only six clients received programmatic services, the additional client did not receive services and was isolating until the facility received the results of the client’s COVID test. It was communicated that the overlap of having up to seven (7) clients was no more than two days. However, the facility is licensed for up to six clients. Based on the information obtained, there is sufficient evidence to support the claim that the facility operated over capacity. 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. Civil penalty assessed for zero tolerance violation.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20201113113519
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: 12/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2021
Section Cited
CCR
81010(a)
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81010(a) Limitations on Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation. This requirement is not met as evidenced by:
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The Licensee Representative agreed to do the following:
Submit a Statement of Understanding, detailing how the facility will maintain compliance as it relates to capacity limitation. Submit statement by 12/15/2021.
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Based on interview and record review, the licensee did not comply with the section cited above, as the facility operated over capacity, which poses an immediate health and safety risk to clients 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: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/13/2020 and conducted by Evaluator Ashley Smith
COMPLAINT CONTROL NUMBER: 29-AS-20201113113519

FACILITY NAME:LA VENTANA TREATMENT PROGRAMSFACILITY NUMBER:
567609944
ADMINISTRATOR:KLEIN, DIAHANNFACILITY TYPE:
772
ADDRESS:2479 LA GRANADA DRIVETELEPHONE:
(818) 584-5615
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:6CENSUS: 3DATE:
12/13/2021
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Rebekah Sanchez NortonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Unqualified staff administering medication.
INVESTIGATION FINDINGS:
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5
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9
10
11
12
13
Licensing Program Analyst (LPA) Ashley Smith arrived unannounced for a subsequent complaint visit. The LPA initially met with Clinical Director Rebekah Sanchez Norton and explained the reason for the visit. Shortly thereafter, the LPA met with License Steve Zamarripa and Chief Clinical Officer Sharon Volner.

During the initial virtual visit on 11/17/2020, LPA Smith and LPA KaSandra Lopez conducted a virtual tour at 10:40 a.m. and requested documents. During the visit conducted on 10/5/2021, the LPA conducted a tour at 9:50am, conducted a medication audit from 10:05 a.m. – 10:40 a.m., and interviewed staff at 9:59am, 10:49am, 10:53am, 11:01am, and 11:09am. During today’s visit, the LPA interviewed staff from 12:20 p.m. – 12:50 p.m., and obtained documents.


CONT 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
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 5
Control Number 29-AS-20201113113519
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: 12/13/2021
NARRATIVE
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Regarding the allegation: Unqualified staff administering medication.

It was alleged that unqualified staff were administering medications, as they were not licensed. A review of the facility Plan of Operation and interviews confirmed that staff whom assist clients with the self-administration of medication are not required to be licensed but are required to be trained. A review of facility files confirmed that current staff were trained to assist clients with the self-administration of medication. During a visit conducted on 10/05/2021, the LPA conducted a medication audit with the Director of Nursing from 10:05 a.m. – 10:40 a.m., and no discrepancies were identified. Interviews confirmed that staff receive annual medication training and monthly in-service trainings, which also cover topics pertaining to clients self-administering medication. Based on the information obtained, there is insufficient evidence to support the claim that unqualified staff administer medication. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5