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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609958
Report Date: 12/08/2022
Date Signed: 12/08/2022 01:43:03 PM

Unsubstantiated


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
09/29/2022 and conducted by Evaluator Kasandra Lopez
COMPLAINT CONTROL NUMBER: 29-AS-20220929092157
FACILITY NAME:TREMONT HOME CARE, INC.FACILITY NUMBER:
567609958
ADMINISTRATOR:GRAHAM, LISAFACILITY TYPE:
735
ADDRESS:6694 TREMONT CIRCLETELEPHONE:
(805) 553-8451
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 2DATE:
12/08/2022
UNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Lisa GrahamTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility did not have adequate staffing to provide for the care and supervision of residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced subsequent inspection at the facility to deliver findings regarding the above allegations. Tri-Counties Regional Center Quality Assurance Specialists (QAS) Katy Robison and Ryan Landseadel were also present. The parties met with Administrator Lisa Graham at 12:07 PM and explained the reason for the visit.

On 09/29/2022, Community Care Licensing Division received a complaint alleging “Facility did not have adequate staffing to provide care and supervision of clients”. On 10/04/2022, LPA Lopez, QAS Robison, and QAS Lanseadel conducted an unannounced inspection at the facility. Interviews were conducted with Administrator Lisa Graham and Client #1 (C1).

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

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
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 2
Control Number 29-AS-20220929092157
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: TREMONT HOME CARE, INC.
FACILITY NUMBER: 567609958
VISIT DATE: 12/08/2022
NARRATIVE
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On 10/07/2022, LPA Lopez, QAS Robison, and QAS Landseadel conducted a telephonic interview with Witness #1 (W1). On 10/11/2022, LPA Lopez, QAS Robison and QAS Landseadel conducted telephonic interviews with Witness #2 (W2) and Staff #1 (S1). On 10/26/2022, a collateral inspection was conducted and LPA Lopez and QAS Robison conducted an interview with Client #2 (C2).

Interviews revealed Administrator Lisa Graham was hospitalized on approximately 09/22/2022 through 09/24/2022. During this time, Staff #1 (S1) provided care and supervision for the clients until 09/24/2022. Interviews revealed clients were not left without supervision during this time. On 09/23/2022, C1 went to their family’s private home voluntarily and C2 went to their family’s private home on 09/24/2022. The Administrator returned to the facility on 09/24/2022 and advised the clients they could return back to the home, although the clients declined to do so and chose to stay with their family longer.

Based on the information obtained, there is insufficient evidence to support the allegation occurred. Therefore, the allegation of Facility did not have adequate staffing to provide care and supervision of clients is unsubstantiated at this time. Exit interview conducted. A copy of the report was emailed.

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

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
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