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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850339
Report Date: 03/01/2024
Date Signed: 03/01/2024 02:48:58 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
12/18/2023 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20231218082642
FACILITY NAME:INN AT THE PARK VENTURAFACILITY NUMBER:
195850339
ADMINISTRATOR:ANGUIANO, ROSEFACILITY TYPE:
740
ADDRESS:21200 VENTURA BLVDTELEPHONE:
(818) 884-7100
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:200CENSUS: DATE:
03/01/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rose Anguiano TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate supervision resulting in resident wandering away from facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate allegation listed above. During today’s visit, LPA met with Administrator Rose Anguiano and explained the reason for the visit.

On 12/22/2023, from 10:30 a.m. – 12:00 p.m., LPA conducted an unannounced complaint investigation for the allegation listed above. During the visit, LPAs toured the physical plant, interviewed staff, and reviewed and obtained pertinent documents relevant to the investigation.

It was reported that staff did not provide adequate supervision resulting in Resident #1 (R1) wandering away from facility. On 12-16-2023, it was reported that R1 left the facility then was admitted into a local hospital after having a medical emergency at a store located near the facility. Interviews conducted and records review reflected that according to R1's LIC 602 (Physician's Report), they are "able to leave the facility unassisted" and is independent with activities of daily living.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
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 2
Control Number 29-AS-20231218082642
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: INN AT THE PARK VENTURA
FACILITY NUMBER: 195850339
VISIT DATE: 03/01/2024
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
Continued from 9099

R1 is also self-responsible.R1 has a history of walking around the nearby community and was often out running errands. LPA's records review and observations revealed  residents are required to sign in and out upon leaving the facility as it is in the admissions agreement and there is signage by the front desk. R1 would not often abide by those rules.   Records review of staff schedule further revealed there were six (6) caregivers and a med tech on shift. LPA's interviews with five (5) staff revealed that before any resident exits the building they are reminded to sign out and most residents comply. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation “Staff did not provide adequate supervision resulting in R1 wandering away from facility” is deemed Unsubstantiated at this time.

Exit interview conducted/No citations issues/ A copy of report was provided.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2