<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610026
Report Date: 08/17/2022
Date Signed: 08/17/2022 12:22:41 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
03/25/2022 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20220325100025
FACILITY NAME:FAITH MANORFACILITY NUMBER:
567610026
ADMINISTRATOR:ATAKEEV, ASKARFACILITY TYPE:
740
ADDRESS:128 ERTEN STREETTELEPHONE:
(805) 370-8388
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
08/17/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Emily MosquitoTIME COMPLETED:
12:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to meet resident's needs.
Staff failed to administer resident's medication as prescribed.
Staff failed to allow resident use of personal wheelchair.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegations. On 03/25/2022, LPA Guzman Chavez conducted an initial 10-day complaint inspection. Upon arrival, LPA met with Staff, Emily Mosquito and was explained the reason for the visit. Staff called the Administrator, Solomon Gochin at 10:50 a.m., but he was unavailable to come to the facility. Entrance interview conducted.

During the initial visit on 03/25/2022, at 1:10 p.m., LPA Guzman Chavez conducted a physical plant tour, interviewed one staff, six residents, obtained copies of pertinent documents, and interviewed one family member at 2:35 p.m. The LPA also conducted a medication audit at 3:00 p.m.

...Report Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
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-20220325100025
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: FAITH MANOR
FACILITY NUMBER: 567610026
VISIT DATE: 08/17/2022
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...

It was alleged that staff failed to meet resident’s needs. It was reported that staff do not speak English and ignore the residents’ needs. It was also reported that resident was receiving poor care. Interviews with staff revealed there is no language barrier between the residents and staff as they are able to communicate in English. During the inspection visit on 03/25/2022, the LPA had no issues communicating with the staff as they were able to understand and speak English. Interviews with residents revealed staff assist at all times and the care received has been nothing but good. Residents stated staff do their best with all the residents and expressed no concerns. Furthermore, family member stated resident’s medical condition has been doing a lot better since moving into the facility. The staff assist the residents when they need help and feel their needs are being met. Based on the evidence gathered through interviews, the Department does not have sufficient evidence to support the allegation of, “staff failed to meet resident’s needs”. Therefore, the allegation is deemed Unsubstantiated at this time.

It was also alleged that staff failed to administer resident's medication as prescribed. It was reported that Resident #1 (R1) was not receiving pain medication at night. Interviews conducted revealed R1 had recently moved out; therefore, medication audit was conducted on random resident’s medication. Medication audit for Resident #2 (R2) revealed that on the centrally stored medication log, prescription Lisinopril quantity two-hundred (200) is prescribed to be taken one (1) tablet twice a day, was filled on 02/23/2022 and started on 03/06/2022, had one-hundred sixty-one (161) tablets remaining in the bottle. Furthermore, medication audit for Resident #3 (R3) revealed that on the centrally stored medication log, prescription Metformin quantity sixty (60) is prescribed to be taken one (1) tablet twice a day, was filled on 03/10/2022 and started on 03/14/2022, had thirty-seven (37) tablets remaining in the bottle. Interviews conducted revealed that staff assist residents to take their medication every day. Additionally, residents stated staff deliver the morning medication and vitamins daily during breakfast. Based on the information and documentation obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “staff failed to administer resident's medication as prescribed”. Therefore, the allegation is deemed Unsubstantiated at this time.

...Report Continued on LIC 9099C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220325100025
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: FAITH MANOR
FACILITY NUMBER: 567610026
VISIT DATE: 08/17/2022
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 9099C...

It was further alleged that staff failed to allow resident use of personal wheelchair. It was reported that a new wheelchair was delivered on 03/22/2022 and staff refuse to provide it for the resident. Information obtained revealed that R1 was admitted to the facility on 03/21/2022. Medical Records obtained and reviewed revealed that R1’s doctor had ordered a bed, semi electric with mattress and rails. However, there was no mention of a wheelchair. Interviews conducted with staff revealed that per R1, Kaiser had ordered both a wheelchair and a bed with a mattress. Staff stated the physical therapist had called the next day to report items were not received yet. Furthermore, R1 had seen another resident’s wheelchair in the facility and wanted to use it. Staff had asked permission from the other resident to see if it was okay for R1 to use in the meantime. But the resident refused to share the wheelchair with R1. Interviews with R1 confirmed that wheelchair had not been received at the facility yet, and Kaiser was currently working on having items delivered. Based on the information obtained during the course of the investigation, the Department does not have sufficient evidence to support the allegation of “staff failed to allow resident use of personal wheelchair”. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview. No citations issued. Report was reviewed with staff; Emily Mosquito and a copy was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3