565801684-11-2-2021-29-AS-MGCZ-C8DSRY-20211102140707

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801684
Report Date: 11/02/2021
Date Signed: 11/02/2021 02:07:46 PM

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:	SVS-SIMI VALLEY		FACILITY NUMBER:	565801684
ADMINISTRATOR:	LAURA WOOD		FACILITY TYPE:	775
ADDRESS:	2381 TAPO STREET, UNIT D		TELEPHONE:	(805) 582-1752
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	60	CENSUS: 0	DATE:	11/02/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Laura Wood		TIME COMPLETED:	02:05 PM

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	Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced Case Management – Incident visit to the above facility. The purpose of the visit is to conclude an investigation initiated during a Case Management – Incident visit conducted on 02/28/2020 by LPA Mita Amin. During today’s visit, LPA met with Program Director Laura Wood. Entrance interview conducted. On 02/28/2020, from 1:52 p.m. to 2:49 p.m., LPA Amin conducted the initial case management visit to follow up on a self-reported incident pertaining to Client #1 (C1). Per the report, C1 reported to the Adult Day Program (ADP) Director, Laura Wood, that on 2/20/2020, Client #2 (C2) inappropriately touched C1 in the facility van during a return trip from an outing. There were four (4) clients and one (1) staff/driver in the vehicle. The driver and other clients denied seeing or hearing anything unusual. During the visit, LPA Amin toured the facility and obtained copies of pertinent documents. No immediate health and safety hazards were observed during the visit. The case was referred to Community Care Licensing Investigations Branch (IB) and assigned to Investigator Lorraine Patterson. On 02/28/2020, Investigator Patterson was notified that the Simi Valley Police Department (SVPD) did not have any recent contact with C1 and there were no police contacts on file which involved C2 or the Adult Day Program. Investigator Patterson conducted interviews with the ADP Director on 04/09/2020 at approximately 1:41 p.m.; with Client #3 (C3) on 04/14/2020 at approximately 12:23 p.m.; with Staff #1 (S1) at approximately 2:03 p.m.; and with C2 on 04/15/2020 at approximately 11:56 a.m. Between 04/09/2020 and 04/14/2020, Investigator Patterson made several attempts and left messages for Client #4 (C4) with no return call. Continued on LIC 809C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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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: SVS-SIMI VALLEY	FACILITY NUMBER: 565801684
	VISIT DATE: 11/02/2021

NARRATIVE

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Continued from LIC 809

Between 04/09/2020 and 04/15/2020, Investigator Patterson made several attempts to contact C1 and C1’s family member. On 04/15/2020, Investigator Patterson contacted C1 about the allegation. During the attempt to interview, C1 hung up on Investigator Patterson. Investigator Patterson left messages but did not receive any return phone calls from either C1 or C1’s family member. On 04/16/20, Investigator Patterson conducted an interview with C1’s Tri-Counties Regional Center (TCRC) Service Coordinator.

Investigator Patterson obtained and reviewed the facility files for C1 and C2 which revealed they have a history of similar complaints; and as a precaution the ADP has enacted an action plan in place for C1 and C2. Interviews were conducted and C1 refused to be interviewed. The staff and C1’s TCRC Service Coordinator reported that C1 lacks personal boundaries and has a history of reporting then recanting complaints. The driver and C3 who were in the vehicle denied witnessing the alleged incident. C2 denied the allegation. The investigation further revealed that C1’s husband, who is also a client at the ADP, may have been a contributing factor in C1’s self-report. Based on all information gathered, there is insufficient evidence to determine that due to neglect/lack of care and supervision C2 inappropriately touched C1 at this time.

Exit interview. A copy of the report was emailed.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC809 (FAS) - (06/04)

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