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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608302
Report Date: 07/12/2024
Date Signed: 07/12/2024 12:49:25 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
03/08/2024 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20240308132909
FACILITY NAME:LANCASTER HAVEN RCFEFACILITY NUMBER:
197608302
ADMINISTRATOR:MARIA MAXIMA BASCOS, RNFACILITY TYPE:
740
ADDRESS:1755 WEST LANCASTER BLVD.TELEPHONE:
(661) 212-7939
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY:6CENSUS: 4DATE:
07/12/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Teodoro TrippTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are providing expired and left over food to a resident
Staff retained residents with a prohibited health condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility to investigate the above allegation. LPA met with administrator, Teodoro Tripp, and explained the reason for the visit.

--- Staff are providing expired and left over food to a resident

It was alleged that residents are being fed expired and leftover foods. To investigate the allegation, on 07/12/2024, LPA conducted a physical plant tour at around 10:15 AM, interviewed three (03) out of four (04) residents from 10:45 AM to 11:15 AM and interviewed two (02) staff from around 11:15 AM to 12:00 PM. During the physical plant tour, LPA did not observe any expired foods. During interviews with staff, all staff stated they do not serve expired or leftover foods, that they label and check all foods periodically to discard anything before it expires.
(CONT. LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
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 2
Control Number 31-AS-20240308132909
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: LANCASTER HAVEN RCFE
FACILITY NUMBER: 197608302
VISIT DATE: 07/12/2024
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 with residents, all interviewed residents, including Resident #1 (R1), stated that the food is great and are unaware of being served expired or leftover food. LPA was unable to interview one (01) out of four (04) residents.

Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

--- Staff retained residents with a prohibited health condition

It was alleged that residents in the facility are on gastrostomy tubes. To investigate the allegation, on 07/12/2024, LPA conducted a physical plant tour at around 10:15 AM, requested documents at around 11:15 AM and interviewed two (02) staff from around 11:15 AM to 12:00 PM. During the physical plant tour, LPA did not observe gastrostomy tubes as residents were covered. A review of the Admissions Agreement and Hospice Plan of Care which indicates dates of admission and that Resident #2 (R2) and Resident #3 (R3) were admitted to the facility under hospice care with a plan of care for their gastrostomy tubes. During interviews with staff, all staff stated there are two (02) residents in the facility with gastrostomy tubes. Staff #1 (S1) added that residents were on hospice when admitted to the facility with nursing plan of care and were never in the facility as a standard client.

Although gastrostomy tubes are deemed a prohibited health condition, facility has Hospice Care Waiver and is not required to submit written exception requests for residents or prospective residents with restricted health conditions as the residents have been diagnosed as terminally ill and are receiving hospice services in accordance with a hospice care plan and the treatment is specifically addressed in the hospice care plan.

Based on interviews and record review, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

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

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2