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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610007
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:18:17 PM


Document Has Been Signed on 01/18/2024 03:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:VARENITA OF SIMI VALLEYFACILITY NUMBER:
567610007
ADMINISTRATOR:VEIS, MARGIEFACILITY TYPE:
740
ADDRESS:3921 COCHRAN STREETTELEPHONE:
(805) 327-1100
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:110CENSUS: 100DATE:
01/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Margie VeisTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPA’s) Martha Arroyo and Brian Balisi conducted an unannounced case management visit to the above facility. The purpose of this visit is to conclude an investigation regarding an incident that occurred on 01/01/2024. Upon arrival, the LPAs met with Executive Director (ED), Margie Veis, and explained the reason for the visit. Entrance interview.

On 01/02/2024, the Department received an incident report stating that on the morning of 01/01/2024, Staff #1 (S1) was assisting Resident #1 (R1) with dressing. R1 was resistant to care and became agitated. R1 slapped S1 across the face, causing S1’s glasses to fall off their face and in response, S1 slapped R1 across the face. Staff #2 (S2) witnessed the incident as they were inside the room assisting S1.

During the initial visit on 01/05/2024, LPA Arroyo conducted a tour of the Memory Care Unit at 12:20 p.m., conducted interviews with the ED and two staff between 12:13 p.m. and 12:45 p.m., conducted a file review at 1:05 p.m., and obtained copies of pertinent documents relevant to the investigation.

Information obtained during the course of the investigation revealed that R1 was agitated while being provided care by both S1 and S2. This resulted in R1 slapping S1 causing their glasses to fall from S1’s face. In response, S1 slapped R1 across the face. Interviews conducted revealed that S2 had seemed short tempered with the residents lately and S2 had reported to other staff that it was only a reaction that happened without thinking due to being slapped.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VARENITA OF SIMI VALLEY
FACILITY NUMBER: 567610007
VISIT DATE: 01/18/2024
NARRATIVE
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(Report Continued from LIC 809C...)

However, staff stated observing S2 being slapped by other residents in the past but denied seeing any reaction from S2. In addition, both law enforcement and R1’s family were contacted and notified of the incident on the same day it occurred. Hospice was also notified shortly after the incident to come to the facility and educate the staff on how to deal with residents’ behaviors. Furthermore, S1 resigned from their position on their own following the incident. Based on the information obtained and reviewed, the Department has enough evidence to say that S1 slapped R1 while providing care.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies were observed and cited during the visit.



Exit Interview conducted. Copy of report, and appeal rights provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/18/2024 03:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: VARENITA OF SIMI VALLEY
FACILITY NUMBER: 567610007

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2024
Section Cited
CCR
87468.1(a)(1)(3)

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87468.1(a)(1)(3) Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the
elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships
with staff… and to be free from...
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The Licensee has agreed to conduct an in-house training on residents’ personal rights and submit proof to CCL no later than 01/19/2024.
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punishment, humiliation, intimidation, abuse, or other actions of a punitive
nature… This requirement was not met as evidenced by:
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Based on the information obtained and reviewed, the Licensee did not comply with the section cited above as
S1 slapped R1 while providing care, which posed an immediate safety 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.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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