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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609015
Report Date: 03/11/2025
Date Signed: 03/11/2025 03:37:50 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
03/06/2025 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20250306131914
FACILITY NAME:CARING HEARTS SENIOR CARE HOME LLCFACILITY NUMBER:
197609015
ADMINISTRATOR:AMORSOLO-SAMANIEGO, MARITAFACILITY TYPE:
740
ADDRESS:4144 VAHAN COURTTELEPHONE:
(661) 794-9940
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 6DATE:
03/11/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lily Anne Gagarin / Assistant AdministratorTIME COMPLETED:
03:47 PM
ALLEGATION(S):
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Staff yelled at resident.
INVESTIGATION FINDINGS:
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On 03/11/2025 at 11:00 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conduct an unannounced, initial complaint visit. Upon arrival, LPA met with staff and requested they contact the administrator. Staff contacted the administrator. At approximately 11:15 am., LPA met with the Assistant Administrator Lily Anne Gagarin. According to Lily Anne the administrator is unavailable today. Lily Anne will be signing today's report.

Allegation: Staff yelled at resident. In regards to the allegation is was reported that a male staff in a raised angered voice scolded resident #1(R1). To investigate the allegation at 11:18 a.m. LPA requested a copy of the resident roster, personnel report (LIC500), and staff schedule. According to the assistant administrator, one (1) resident is currently hospitalized and the LIC 500 needs to be updated to include two new permanent staff and one on call staff. At approximately 11:25 a.m., LPA conducted a physical plant tour of the facility to ensure the health and safety of the residents in care. (Continue to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
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 3
Control Number 31-AS-20250306131914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARING HEARTS SENIOR CARE HOME LLC
FACILITY NUMBER: 197609015
VISIT DATE: 03/11/2025
NARRATIVE
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(Continued form LIC 9099) From approximately 11:40 a.m. to 12:20 p.m., LPA conducted interviews with three (3) out of six (6) current residents. R1 is no longer in the facility. The three (3) residents not interviewed were sleeping, at the hospital, or did not respond to LPA's questions. From approximately 12:20 p.m to 12:50 p.m., LPA conducted interviews with two (2) staff present and the assistant administrator. From 12:50 p.m. to 1:45 LPA reviewed resident and staff records and requested copies of residents Physician's Reports (LIC602A) and Appraisal / Needs and Services Plan (LIC625).

LPA's interview with staff revealed they have never witnessed staff yelling at residents and deny they have yelled or raised their voice at residents. LPA's interview with three (3) out of the three (3) residents that were interviewed deny staff yelling at them. Interview with Two (2) out of the three (3) residents interviewed deny witnessing staff yell at other residents. LPA's interview with one (1) out of the three (3) residents revealed they have heard a "female" voice yell but did not recall if it was towards another resident, when it had occurred or what time of day it happened. LPA's interview with the assistant administrator revealed they had received a complaint a few weeks ago form a resident's family member about how staff treated the resident. According to the assistant administrator staff #1 (S1) and staff #2 (S2) were let go as a precaution and for not providing assistance. The assistant manger also informed LPA they do not believe S2 had yelled at R1 but that S2 has a "managerial" voice in general and that it may have been misinterpreted as yelling. LPA was unable to corroborate allegation. Although the allegation may have happened or is valid, there is not enough evidence to prove the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated.

Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3