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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602316
Report Date: 06/01/2023
Date Signed: 06/01/2023 03:41:13 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/30/2023 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20230530195338
FACILITY NAME:SANTA CLARITA HOME FOR THE ELDERLY #3FACILITY NUMBER:
197602316
ADMINISTRATOR:FRASER, NENITAFACILITY TYPE:
740
ADDRESS:28000 TOTHILL DRIVETELEPHONE:
(661) 296-7674
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY:6CENSUS: 6DATE:
06/01/2023
UNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Mely CabarlesTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure residents do not have access to sharp items.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to this facility to investigate the above allegations. LPA met with staff, Mely Cabarles, and explained the reason for the visit. The Administrator designated Mely Cabarles as the responsible person to sign and accept this report.

--- Staff does not ensure residents do not have access to sharp items.

It was alleged that staff left a white magnet key on a drawer that houses sharp items. To investigate the allegation, on 06/01/2023 LPA conducted a physical plant tour at around 1:00 PM and interviewed staff from 1:45 PM – 2:25 PM. During the physical plant tour, LPA observed kitchen cabinet for sharps and knives was locked and that key was with staff.

(CONT. LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
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 2
Control Number 31-AS-20230530195338
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SANTA CLARITA HOME FOR THE ELDERLY #3
FACILITY NUMBER: 197602316
VISIT DATE: 06/01/2023
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
During interviews, Staff #1 (S1) and Staff #2 (S2) they stated that the key was hanging on the cabinet during visit by other parties, but that during the visit S1 was in the kitchen preparing to cook, clean and put the dishes and utensils away.

Based on the information revealed from interviews, S1 left the key on the cabinet, however, during the visit by other parties S1 was working in the kitchen, able to supervise residents and able to prevent resident access to sharps and knives. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

An exit interview was conducted, and a copy of the report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2