567609979-3-8-2022-29-AS-DPEA-CDEM6A-20220412091936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609979
Report Date: 03/08/2022
Date Signed: 03/08/2022 04:52:15 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
03/07/2022 and conducted by Evaluator Kasandra Lopez

COMPLAINT CONTROL NUMBER: 29-AS-20220307111155

FACILITY NAME:	RON AND TESS HOME CARE LLC		FACILITY NUMBER:	567609979
ADMINISTRATOR:	SACOLLES, TERESA P.		FACILITY TYPE:	740
ADDRESS:	4810 JUSTIN WAY		TELEPHONE:	(805) 246-5831
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 5	DATE:	03/08/2022
		UNANNOUNCED	TIME BEGAN:	01:13 PM
MET WITH:	Teresa Sacolles		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff pushed resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) KaSandra Lopez conducted an unannounced initial 10 day complaint investigation at the facility today regarding the above allegation. When the LPA arrived there were three caregivers and five residents present. Entrance interview was conducted and the reason for the inspection was explained. Administrator Teresa Sacolles arrived at the facility at 1:29 PM.

During today's inspection, the LPA conducted a physical plant tour beginning at 1:20 PM. Between 1:25 PM and 2:28 PM, the LPA conducted interviews with five residents and three staff members and reviewed facility records at 2:32 PM. The LPA also conducted a telephone interview with Individual #1 (I1) at 2:47 PM.

The allegation of 'Staff pushed resident while in care' alleges Staff #1 (S1) pushed Resident #1 (R1) on three separate occasions while S1 was assisting R1 get in their bed. No injuries were sustained during the alleged incidents. Report continued on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20220307111155

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: RON AND TESS HOME CARE LLC	FACILITY NUMBER: 567609979
	VISIT DATE: 03/08/2022

NARRATIVE

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Interviews with residents revealed no issues or concerns regarding how they are being treated by facility staff. Interviews also revealed S1 no longer assists R1 and R1 feels safe living in the facility. Staff interviewed denied pushing or being rough with any residents in the home or observing any staff push or be rough with any residents. During the interview with S1, S1 denied ever pushing R1 or being rough when assisting R1 in bed. The telephone interview with I1 revealed had no issues or concerns pertaining to the care R1 received at the facility.

Based on the information obtained during the investigation, there is insufficient evidence to support the allegation of 'Staff pushed resident while in care' occurred. Therefore, the allegation is deemed unsubstantiated at this time.

Exit interview and report reviewed with the Administrator. A copy of the report will be emailed.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Kasandra Lopez	TELEPHONE: (818) 421-5183
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC9099 (FAS) - (06/04)

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