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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609306
Report Date: 03/21/2022
Date Signed: 03/21/2022 06:09:17 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/30/2021 and conducted by Evaluator Elsie Campos
COMPLAINT CONTROL NUMBER: 29-NP-20211230095404
FACILITY NAME:ELAINE'S PLACEFACILITY NUMBER:
197609306
ADMINISTRATOR:BOTE, ELAINE PFACILITY TYPE:
740
ADDRESS:22745 DOLOROSA STREETTELEPHONE:
(818) 340-7769
CITY:WOODLAND HILLSSTATE: ZIP CODE:
91367
CAPACITY:6CENSUS: DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Elaine BoteTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Facility failed to protect resident from psychological/mental abuse
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Elsie Campos arrived unannounced for a subsequent complaint visit to deliver findings for the above allegation. The LPA met with staff Norma Gregorio and explained the reason for the visit. Administrator Elaine Bote arrived shortly thereafter.

During today’s visit, the LPA interviewed staff at 2:40 p.m., 2:45 p.m. and collected documents at 3:00 p.m. The LPA interviewed a resident at 2:30 p.m., a resident family member at 3:35 p.m. and additional residents at 4:57 p.m., 5:01 p.m., 5:03 p.m. and 5:57 p.m. Additional staff and resident interviews were conducted at the initial complaint visit on 1/4/2022.

Continued on LIC-9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
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 29-NP-20211230095404
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELAINE'S PLACE
FACILITY NUMBER: 197609306
VISIT DATE: 03/21/2022
NARRATIVE
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Regarding the allegation: Facility failed to protect resident from psychological/mental abuse.
On 12/30/2021, the Department received a complaint, alleging that the facility failed to protect resident from psychological/mental abuse. Interviews conducted with staff revealed that they have not encountered any situations or observed any staff acting inappropriately with residents. Staff interviews and family member interviews revealed that there is no knowledge of any incidents of psychological or mental abuse in this facility. Resident #1 (R1) family member stated that facility staff treat R1 well and had no concerns with the provided care, they are very happy with staff who are caring and attentive. Family member disclosed that R1 often makes false accusations against staff, doctors, and family members as a result of worsening cognitive impairment. Resident interviews revealed that residents feel comfortable residing in this facility and believe they are being treated well. R1 revealed that they are not scared of staff and feels safe.

Based on the information obtained, there is insufficient evidence to support the claim that: Facility failed to protect resident from psychological/mental abuse. This allegation is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2