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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850339
Report Date: 07/30/2024
Date Signed: 07/30/2024 01:44:51 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
02/29/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240229131712
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: 176DATE:
07/30/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Rose AnguianoTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not prevent unknown individual from stealing resident's personal belongings

Staff did not prevent unknown individual from trespassing into facility premises
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to continue investigation for the above allegations. During today’s visit, LPA met with Rose Anguiano and explained the reason for the visit. During the visit Rose had to leave due to an appointment, but stated Tina can sign in their place.

On 3/01/2024, the initial complaint visit was conducted by LPA Brian Balisi between approximately 09:45 a.m. - 3:00 p.m. During the visit, LPA’s conducted physical plant, interviewed staff, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. On 07/24/2024, LPA interviewed Staff #1 (S1).

It was reported that “Staff did not prevent unknown individual from stealing resident’s personal belongings” and “staff did not prevent unknown individual from trespassing into facility premises”, as it was alleged that a houseless person entered Resident #1 (R1)’s room and slept on their bathroom floor.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
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 3
Control Number 29-AS-20240229131712
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: 07/30/2024
NARRATIVE
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Continued from 9099

Interviews conducted and records review reflected that on 02/09/2024, at approx. 02:30am, S1 and Staff #2 (S2) were making their rounds and noticed R1’s room closed, and the lights were turned off. During the night R1’s room is typically slightly open with a light on. S1 entered the room and observed R1 to be agitated and informed S1 to check their bathroom. S1 opened the bathroom door and observed a houseless person sleeping on the bathroom floor. 911 was called immediately and came to the facility within 5 minutes. Police took houseless person into custody and exited the facility. During search of the body of the houseless person, police officers recovered a glasses case, a pair of reading glasses and a debit card with R1’s name on it. Interviews with staff further revealed the houseless person is a known trespasser in the surrounding area and they believe the person was able to enter the facility due to one of the exterior doors not being closed and monitored properly. Since this incident occurred the facility has established direct line of communication with local authorities for extra support and added additional staffing during the NOC shift to sufficiently monitor the property. No trespassing incidents have been reported since. Based on information gathered over the course of the investigation, the Department has sufficient evidence to determine the allegations occurred. Therefore, the allegations that “Staff did not prevent unknown individual from stealing resident’s personal belongings” and Staff did not prevent unknown individual from trespassing into facility premises” has been deemed Substantiated at this time.

Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 6, the following deficiencies were observed and cited (9099-D) during the visit.

Exit Interview Conducted / Appeal Rights discussed and a copy of this report has been issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240229131712
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/31/2024
Section Cited
CCR
87464(f)(2)
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87464(f)(2)- Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services.

This requirement is not met as evidenced by:
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Licensee agreed to review section cited and provide a statement of understanding as well as a written plan to monitor building during NOC shift to CCL via email by COB 7/31/2024
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Based on interviews and record review, the licensee did not comply with the above section by failing to protect a resident from an unwanted intruder entering a private room, which posed an immediate health , safety and personal rights risk to residents in care.
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Type B
08/09/2024
Section Cited
CCR
87468.2(25)
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87468.2 (25) - To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154.

This requirement is not met as evidenced by:
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Licensee agreed to review section cited and provide a statement of understanding to CCL via email by COB 08/09/2024.
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Based on interviews and records review, the licensee did not comply with the section cited above as multiple personal items of R1 were in possession of a houseless person who entered R1’s room while in care, which posed 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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3