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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608857
Report Date: 12/21/2021
Date Signed: 12/21/2021 03:43:12 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
11/02/2021 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20211102115001
FACILITY NAME:SARA'S HOME AWAY FROM HOMEFACILITY NUMBER:
197608857
ADMINISTRATOR:DANIEL D. CHOFACILITY TYPE:
740
ADDRESS:23820 VIA JACARATELEPHONE:
(661) 388-4464
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 5DATE:
12/21/2021
UNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Dulce Catajay, StaffTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff are not wearing PPE
Staff are not allowing visitors in the facility
INVESTIGATION FINDINGS:
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At 2:57pm Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent complaint visit to deliver the finings for the above stated allegations. LPA met with staff - Dulce Catajay, and explained the reason for the visit.

Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. LPA conducted a physical walk through, at approximately, 3:05pm to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit.

An initial 10-day complaint visit conducted on 11/09/2021. During that visit LPA Panushkina conducted interviews (between 10:25amd to 12:00pm) with the Administrator, 2 out of 2 staff, 3 out of 3 residents and reviewed facility records which include: Facility Visitor's Log, Physician Report and Appraisal Needs and Services for R3 the same day, at approximately 10:45am.
Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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-20211102115001
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: SARA'S HOME AWAY FROM HOME
FACILITY NUMBER: 197608857
VISIT DATE: 12/21/2021
NARRATIVE
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Allegation: Staff are not wearing PPE.

Interviews with an Administrator and 2 out of 2 staff indicated that staff always wears their mask, with an exception, when R3 is being assisted by a staff, staff usually don’t wear the mask because R3 is afraid of the mask and gets agitated. Interviews with 2 out of 3 residents, who were able to communicate, also indicated that staff always wearing mask.

During today’s visit, LPA observed staff member wearing their face mask and following facility Mitigation Plan (RE: COVID).

Allegation: Staff are not allowing visitors in the facility.

Interviews with an Administrator and 2 out of 2 staff indicated that aside from requiring proof of vaccination the facility allows visitations with no other restrictions. Interview with 1 out of 3 residents indicated that the facility always allows family to visit (at any time), but due to Government restrictions family doesn't visit as often as they used to.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove

that alleged violations did or did not occur, therefore the above two allegations are unsubstantiated.

No deficiencies issued.

Exit interview conducted, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2