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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610230
Report Date: 11/02/2022
Date Signed: 11/02/2022 02:18:23 PM

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
10/27/2022 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20221027132137
FACILITY NAME:JUST LIKE HOME B&C, INC.FACILITY NUMBER:
197610230
ADMINISTRATOR:ALVAREZ, ANDRIEFACILITY TYPE:
740
ADDRESS:27209 CABRERA AVENUETELEPHONE:
(818) 256-9138
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY:6CENSUS: 5DATE:
11/02/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cielo YorkTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Staff are not wearing masks.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA met with Cielo York and explained the reason for the visit. The administrator, Andrie Alvarez, designated Cielo York as the responsible staff member to sign and accept this report.

--- Staff are not wearing masks.

It was alleged that staff are not wearing masks while around residents. To investigate this allegation, on 11/02/2022, LPA made observations during a physical plant tour at 10:00 AM, interviewed three (03) out of three (03) staff in-person from 10:35 AM – 11:15 AM and interviewed the Administrator via telephone at 11:45 AM. Upon entry, LPA observed that Staff #1 (S1), who answered the door, and Staff #2 (S2), who was seen in the dining room area, were not wearing masks and Staff #3 (S3) was in the restroom.

(Cont. on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
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 3
Control Number 31-AS-20221027132137
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: JUST LIKE HOME B&C, INC.
FACILITY NUMBER: 197610230
VISIT DATE: 11/02/2022
NARRATIVE
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During interviews, LPA asked why S1 and S2 were not wearing masks, they both stated that they “just finished using the restroom”. When LPA interviewed the Administrator, they admitted to not wearing a mask during a visit by the local Ombudsman and stated that they thought it was only a requirement for the unvaccinated. Based on observations and interviews, the allegation is 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):

No other health and safety hazards observed during the visit.

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

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20221027132137
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: JUST LIKE HOME B&C, INC.
FACILITY NUMBER: 197610230
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2022
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.
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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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This requirement is not met as evidenced by;
Based on observations and interviews, the licensee did not ensure that staff are wearing masks at all times while at the facility 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: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3