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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610007
Report Date: 08/14/2023
Date Signed: 08/14/2023 10:49:56 AM

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
07/31/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20230731111448
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: 87DATE:
08/14/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Margie VeisTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility is unsanitary.
Staff did not provide a safe and comfortable environment for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegations. The initial visit was conducted on 08/04/2023 by LPA M. Arroyo. On today’s visit, LPA Arroyo met with Executive Director (ED), Margie Veis and the reason for the visit was explained. Entrance interview.

During the initial visit on 08/04/2023, the LPA conducted a tour of the facility to ensure there are no health and safety hazards at 10:48 a.m., toured resident bedroom at 10:50 a.m., conducted an interview with the Health Services Director and one resident at 10:15 a.m. and 10:51 a.m., and conducted a resident file review at 11:30 a.m. and obtained copies of pertinent documents.

(Report Continued on LIC 9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
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 5
Control Number 29-AS-20230731111448
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: 08/14/2023
NARRATIVE
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(Report Continued from LIC 9099...)

It was alleged that facility is unsanitary and staff did not provide a safe and comfortable environment for residents. During the LPA walkthrough, the LPA observed Resident #1’s (R1’s) apartment which includes the bedroom, bathroom, and kitchenette. R1’s apartment appeared to be clean. Review of documents revealed the facility has the housekeeping staff on rotation to continuously maintain R1’s room clean. Additionally, the maintenance staff shampoo and wash R1’s bedroom carpet at least once a week to make sure R1’s bedroom is both clean and sanitary. Interviews conducted with staff revealed the facility is working with R1 and their family to accommodate R1 as much as possible but are also taking certain measures to keep R1 safe. Interview conducted with resident revealed the facility provided R1 with an air purifier and a spray to rid of stains and smells. R1 stated they keep the bedroom window open at all times, which allows the air to circulate. Furthermore, during the interview, R1 reported to LPA that they were unable to smell what others claimed and displayed no concern. Based on observation and all the information obtained and reviewed during the course of the investigation, the Department does not have sufficient evidence to support the allegation of, “facility is unsanitary” and “staff did not provide a safe and comfortable environment for residents”. Therefore, these allegations are deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/31/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20230731111448

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: DATE:
08/14/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Margie VeisTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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2
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9
Facility is malodorous.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegation. The initial visit was conducted on 08/04/2023 by LPA M. Arroyo. On today’s visit, LPA Arroyo met with Executive Director (ED), Margie Veis and the reason for the visit was explained. Entrance interview.

During the initial visit on 08/04/2023, the LPA conducted a tour of the facility to ensure there are no health and safety hazards at 10:48 a.m., toured resident bedroom at 10:50 a.m., conducted an interview with the Health Services Director and one resident at 10:15 a.m. and 10:51 a.m., and conducted a resident file review at 11:30 a.m. and obtained copies of pertinent documents.

(Report Continued on LIC 9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
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 5
Control Number 29-AS-20230731111448
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: 08/14/2023
NARRATIVE
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(Report Continued from LIC 9099A...)

It was alleged that facility is malodorous. It was reported that an acrid smell permeates within the facility. During the walkthrough, the LPA observed R1’s bedroom which omitted the smell of pet urine while inside. Interviews conducted with staff revealed R1’s pet is incontinent, and the facility has been trying to maintain and keep up with the pet’s needs. Staff stated the carpet in R1’s bedroom is being washed on a weekly basis to rid of smell of urine. However, there is a lingering smell of pet urine when inside R1’s bedroom. Based on LPA observation during the facility walkthrough, the allegation “facility is malodorous” is deemed Substantiated at this time.

Pursuant to CCR, Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC LIC9099-D). Failure to correct citations can result in civil penalties.


Exit interview conducted. Citation issued. A copy of the Appeal Rights and Report was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230731111448
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: 08/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2023
Section Cited
CCR
87303(a)(1)
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Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.Floor surfaces… shall be maintained in a clean and odorless condition. This requirement is not met as evidenced by:
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The Licensee has agreed to replace carpet in Resident's apartment and submit proof CCL
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Based on LPA observation during the facility walkthrough, the licensee did not comply with the section cited above, as R1’s bedroom has a lingering smell of pet urine, which poses a potential health and 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: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5