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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607020
Report Date: 12/27/2021
Date Signed: 12/27/2021 10:41:17 AM

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
12/14/2021 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20211214120924
FACILITY NAME:JOE-SEPHINE RESIDENTIAL CARE FAC. FOR THE ELDERLYFACILITY NUMBER:
197607020
ADMINISTRATOR:JOSEPHINE C. SANOYFACILITY TYPE:
740
ADDRESS:615 CURVE CIRCLETELEPHONE:
(661) 942-4307
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 2DATE:
12/27/2021
UNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Josephine SanoyTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility is not following COVID-19 guidelines.

Facility staff are not wearing masks.

Residents are not able to receive visitors at the facility.

Residents have access to chemicals at the facility.
INVESTIGATION FINDINGS:
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At 10:02am Licensing Program Analyst (LPA) Shira Stamps arrived at the facility mentioned above for a subsequent complaint visit. Entrance interview conducted.

At approximately 10:05 am, LPA conducted a physical plant walk through, and LPA did not observe any immediate health and safety issues during this visit.

Allegation: Facility is not following COVID-19 guidelines.

Upon arrival to the facility during the initial complaint visit, LPA’s temperature was taken, COVID screening questions were asked, sanitizer was available, and LPA was asked to sign in. On the subsequent visit the same procedure was completed by facility staff. LPA suggested for the Administrator to record the temperatures of guests in the log in book. Therefore, after observations the allegation, “Facility is not following COVID-19 guidelines,” is deemed unsubstantiated. Continued....

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
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-20211214120924
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: JOE-SEPHINE RESIDENTIAL CARE FAC. FOR THE ELDERLY
FACILITY NUMBER: 197607020
VISIT DATE: 12/27/2021
NARRATIVE
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Allegation: Facility staff are not wearing masks.

During the initial complaint visit, LPA observed a facility staff answer the door without a mask on. During the physical plant walk through the staff member put on a mask. All other facility staff was observed to have a mask on. During the subsequent complaint visit, all facility staff was observed wearing a mask. Based upon observations the allegation, “Facility staff are not wearing masks,” is deemed unsubstantiated.

Allegation: Residents are not able to receive visitors at the facility.

Interviews with two (2) out of two (2) staff members indicated that residents can have visitors in the facility. One (1) out of two (2) staff members stated only one (1) resident has family to visit, but they prefer to visit virtually. One (1) out of two (2) residents indicated that they do not have visitors and are unsure why. One (1) out of two (2) residents indicated they do not have visitors because they do not have family that live in the area. LPA reviewed the guest log in book and found multiple guests that have signed in over the span of five (5) months. LPA observed signs on the door stating visitors are welcome. Therefore, after review of the information and interviews conducted the allegation, “Residents are not able to receive visitors at the facility,” is deemed unsubstantiated.

Allegation: Residents have access to chemicals at the facility.

During the initial physical plant walk through, chemicals were found in the locked garage. LPA informed the Administrator to place the chemicals in a locked cabinet in the locked garage for extra security. No chemicals were found accessible to the residents. Therefore, after observations the allegation, “Residents have access to chemicals at the facility,” is deemed unsubstantiated.

Exit interview conducted. Report delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2