567610007-9-26-2022-29-AS-DPEA-CKET26-20221021142014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567610007
Report Date: 09/26/2022
Date Signed: 09/26/2022 04:36:24 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
09/19/2022 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20220919200136

FACILITY NAME:	VARENITA OF SIMI VALLEY		FACILITY NUMBER:	567610007
ADMINISTRATOR:	VEIS, MARGIE		FACILITY TYPE:	740
ADDRESS:	3921 COCHRAN STREET		TELEPHONE:	(805) 327-1100
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	110	CENSUS: 71	DATE:	09/26/2022
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Vida Gonzales (Health & Wellness Director)		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not following COVID-19 protocols.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced initial 10-day complaint visit for the above allegation. Upon arrival, the LPA was advised the Administrator was not in the facility. LPA met with the Health & Wellness Director (HWD), Vida Gonzales and at this time was explained the reason for the visit. Entrance interview conducted.

During today's inspection, at 2:45 p.m., the LPA observed staff and residents in the common areas to ensure there are no health and safety concerns. The LPA also interviewed the WHD at 3:02 p.m.

It was alleged that facility is not following COVID-19 protocols. It was reported that management is not doing any strict protocol regarding Covid and face coverings/masks. During the inspection, at 2:48 p.m., Staff #1 (S1) was not wearing their face mask properly, by having the mask under the chin. The LPA observed S1 continuously placing the mask under the chin. ...Report Continued on LIC 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

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 3

Control Number 29-AS-20220919200136

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: VARENITA OF SIMI VALLEY	FACILITY NUMBER: 567610007
	VISIT DATE: 09/26/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

...Report Continued from LIC 9099...

At 3:00 p.m., the LPA observed five (5) residents in the common area not wearing a face mask, and Staff #2 (S2) with their face mask on their chin while in close proximity of residents. The HWD reported to the LPA the facility was currently having an outbreak that started on 9/05/2022. Ventura Department of Public Health (VDPH) advised facility to do rapid testing twice a week for three weeks until they received two (2) rounds of negative test results. The HWD stated the facility is not restricting visitors into the facility during the outbreak as long as they are wearing face masks. Furthermore, although face masks are being used by the facility staff, the masks are not being worn properly as staff were observed wearing their masks on their chin continuously during the inspection. Based on LPA observation, the above allegation, “facility is not following COVID-19 protocols” is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Appeal Rights Discussed. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20220919200136

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: VARENITA OF SIMI VALLEY	FACILITY NUMBER: 567610007
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/26/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	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: (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Health & Wellness Director has agreed to hold training with all staff about proper mask-wearing and COVID-19 prevention protocol and provide training records to CCL by 09/27/2022.
	8 9 10 11 12 13 14	Based on LPA observation, the licensee did not comply with the section cited above as facility staff were observed NOT wearing masks/face coverings properly (on their chin) while inside the facility during an outbreak, which poses an immediate health, safety, and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3