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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610007
Report Date: 04/22/2023
Date Signed: 05/30/2023 02:53:20 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
08/31/2022 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20220831132941
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: 86DATE:
04/22/2023
UNANNOUNCEDTIME BEGAN:
03:33 PM
MET WITH:Julia Scarpa, Activities DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident care plan not updated
INVESTIGATION FINDINGS:
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A subsequent complaint visit was conducted by Licensing Program Analyst (LPA) to deliver investigation finding regarding above allegation. LPA met with Julia Scarpa, Activities Director. Reason for visit explained.
Following is a summary of the investigation: On 08/31/2022, information was received that a care plan for resident #1 was never reviewed with or signed by R1’s responsible person. Interview with facility staff and records reviewed on 01/23/2023 confirmed that R1 moved into the facility on 01/31/2022; a preplacement/initial appraisal was conducted on 10/21/2021 prior to move in. From 02/2022 – 03/2022 R1 demonstrated exit seeking behaviors and was destructive with items in the community. There was no updated care plan for the time period when R1’s change in condition was observed from 02/2022-03/2022.
LPA was provided with a copy of three different care plans dated 4/12/22, 4/20/22 and 9/1/2022 which did not have signature of R1’s responsible person. Based on the information gathered and records reviewed the claim that “Resident care plan not updated” 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 held. Appeal Rights discussed/Copy of report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2023
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 4
Control Number 29-AS-20220831132941
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: 04/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2023
Section Cited
CCR
87463(c)
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(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff,...when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first,..
This requirement is not met as evidence by:
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Administrator agreed to submit a self certification letter explaining what changes have been made and any inservice training provide to staff as plan of correction for future compliance.
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Based on interviews and resident records review the licensee/facility staff did not comply with the section cited above as R1's reappraisal were not done when a change in condition occured, which poses a potential health, safety and personal rights 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: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
08/31/2022 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20220831132941

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: 86DATE:
04/22/2023
UNANNOUNCEDTIME BEGAN:
03:33 PM
MET WITH:Julia Scarpa, Activities DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident is left soiled while in care
Staff not addressing a resident's incontinence needs
Staff did not properly monitor a resident's change in medical condition
Resident hygiene needs not met

INVESTIGATION FINDINGS:
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This report was amended. See report generated 6/27/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20220831132941
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: 04/22/2023
NARRATIVE
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 This report was amended. See report generated 6/27/2023.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4