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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607020
Report Date: 02/14/2022
Date Signed: 02/14/2022 01:48:26 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., 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:
02/14/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Joesephine Sanoy, AdministratorTIME COMPLETED:
02:00 PM
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 12:55 pm, Licensing Program Analysts (LPAs) Shira Stamps and Joscelyn Martinez conducted a subsequent complaint visit regarding the complaint allegations listed above. LPA met with the facility Administrator Joesphine Sanoy. Entrance interview conducted, and physical plant tour conducted.

This report is being issued based on new information received from a reliable source regarding the following allegations.

Facility is not following COVID-19 guidelines.

Based on a reliable source the facility is not following COVID-19 guidelines, and are not screening visitors. Therefore, after further investigation the allegation, “Facility is not following COVID-19 guidelines,” is deemed substantiated.


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

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
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 5
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: 02/14/2022
NARRATIVE
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Allegation: Residents are not able to receive visitors at the facility.

Based on observation from a reliable source, the facility had a no visitors sign posted. Therefore, upon further investigation the allegation, “ Residents are not able to receive visitors at the facility,” is deemed substantiated.

Allegation: Residents have access to chemicals at the facility.

Based on additional information received from a reliable source, the Administrator had chemicals accessible to residents. The Administrator stated during a visit from the Ombudsman the Administrator left the door unlocked to the closet with the chemicals to answer the door. Therefore, upon further investigation the allegation, “Residents have access to chemicals at the facility, “ is deemed substantiated.



Exit interview conducted, citations issued, and copy of report delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2022
Section Cited
CCR
87468(a)(2)
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87468(a)(2) Personal Rights. (a) Each resident shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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The Licensee agrees to provide current training to all staff members on the subject: the approved mitigation plan. Documentation shall be submitted to LPA by POC date, via email or fax.
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Bases on observations from a reliable source, the licensee did not ensure the personal rights of persons in care to a safe, healthy, and comfortable home and engaged in conduct inimical to the health, welfare, and safety of persons in care, in that facility staff did not wear a mask, and did not follow COVID-19 guidelines by screening visitors.
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Type B
02/21/2022
Section Cited
HSC
1569.313
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1569.313(11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
This requirement is not met as evidenced by:
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The Licensee has completed the plan of action and has previously removed the no visitor’s sign.
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Based on observations from a reliable source, the licensee did not permit residents to have visitors in that the facility had no visitors signs posted.
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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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2022
Section Cited
CCR
87309(a)
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87309(a) Storage Space
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement was not met as evidence by:
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The Licensee has agreed to provide current training to all staff working in the facility, on the subjects of securing toxins and chemicals. Documentation shall be submitted to LPA by POC date, via email or fax.
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Based on observations from a reliable source, the licensee had cleaning solutions accessible 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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: 02/14/2022
NARRATIVE
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 Facility staff are not wearing masks.

Based on observation from a reliable source, the facility staff was not wearing masks. Therefore, upon further investigation the allegation, “Facility staff are not wearing masks,” is deemed substantiated.

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

Based on observation from a reliable source, the facility had a no visitors sign posted. Therefore, upon further investigation the allegation, “ Residents are not able to receive visitors at the facility,” is deemed substantiated.

Allegation: Residents have access to chemicals at the facility.

Based on additional information received from a reliable source, the Administrator had chemicals accessible to residents. Therefore, upon further investigation the allegation, “Residents have access to chemicals at the facility, “ is deemed substantiated.



Exit interview conducted, citations issued, and copy of report delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5