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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607537
Report Date: 09/27/2022
Date Signed: 09/27/2022 11:25:39 AM

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
09/20/2022 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20220920133535
FACILITY NAME:A SAFE HAVENFACILITY NUMBER:
197607537
ADMINISTRATOR:ALAN HURTADOFACILITY TYPE:
740
ADDRESS:22231 BARBACOA DR.TELEPHONE:
(661) 297-3547
CITY:SAUGUSSTATE: CAZIP CODE:
91350
CAPACITY:6CENSUS: 6DATE:
09/27/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Alan HurtadoTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff are not wearing PPE
Staff are not screening visitors regarding Covid-19 guidelines
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA met with, the licensee, Alan Hurtado and explained the reason for the visit.
--- Staff are not wearing PPE
--- Staff are not screening visitors regarding Covid-19 guidelines

It was alleged that staff are not wearing masks and are not screening visitors. To investigate this allegation, on 09/27/2022, LPA made observations during a physical plant tour at 9:45 AM and interviewed two (02) staff from 10:35 – 11:05 AM. LPA observed that all staff were not wearing masks and LPA was not screened upon entry. During the interviews, staff admitted to not following infection control protocols. Based on observations and interviews, the allegations are SUBSTANTIATED at this time.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):
Exit interview was conducted and a copy of report was issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
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 2
Control Number 31-AS-20220920133535
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: A SAFE HAVEN
FACILITY NUMBER: 197607537
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2022
Section Cited
CCR
87470(c)(1)(F)
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87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by;
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87470 Infection Control Requirements; The written letter must be sent to the LPA by the POC due date.
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Based on observations and interviews, the licensee did not ensure that staff are wearing mask at all times while at the facility and that all visitors are screened upon entry which poses an immediate 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: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2