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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610251
Report Date: 06/14/2023
Date Signed: 06/14/2023 04:13:49 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
05/25/2023 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20230525110238
FACILITY NAME:MONDELL PINE MANOR IFACILITY NUMBER:
197610251
ADMINISTRATOR:SOLIS, CANDICEFACILITY TYPE:
740
ADDRESS:39046 MONDELL PINE AVETELEPHONE:
(805) 468-5068
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 4DATE:
06/14/2023
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Cristina AquinoTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Residents are being neglected while in care
Staff failed to provide adequate food service
Staff do not change residents' in a timely manner
INVESTIGATION FINDINGS:
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On 6/14/2023 Licensing Program Analyst (LPA) Melissa Spaeth conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA Spaeth was met by Cristina Aquino. LPA explained the purpose of this visit was to deliver findings for this complaint. LPA interviewed caregiver at 1:00 pm and the facility manager at 1:35 pm.

The investigation consisted of the following: On 6/01/2023, LPA Spaeth conducted a 10-day visit, toured the physical plant and requested documents. LPA Spaeth requested the following documents: 1) staff and resident roster, and 2) residents’ Physician’s Report. All documents were received at the time of visit. LPA Spaeth interviewed R1, R2, and R3. R4 was unable to answer LPA’s questions. LPA interviewed three out of the four residents.

The investigation revealed the following

Regarding the allegation, staff do not change residents in a timely manner, it is alleged that residents are soiled and not cleaned in a timely manner. LPA interviewed three residents who need assistance with
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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-20230525110238
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MONDELL PINE MANOR I
FACILITY NUMBER: 197610251
VISIT DATE: 06/14/2023
NARRATIVE
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changing and the three residents stated do not sit a long time in soiled diaper and also stated staff change resident in a timely manner. Three caregivers stated do not leave residents in a soiled diaper and ensure residents are changed in a timely manner. The Facility Manager stated staff have been trained to change residents in a timely manner and stated has not received complaints from the residents.

Regarding the allegation, Staff failed to provide adequate food service, it is alleged that meals are not served at a scheduled time. R1, R2, and R3 stated meals are served at scheduled times which are 8:00 am breakfast, between 12:00 pm and 1:00 pm for lunch and 5:00 pm is dinner. Three caregivers stated meals are served at scheduled times. The Facility Manager stated caregivers provide meals in a timely manner and have not received complaints from the residents.

Regarding the allegation, residents are being neglected while in care, it is alleged that a staff member is drinking inside the facility. R1, R2, and R3 stated has never seen a staff member drinking within the facility. Also, the three residents stated the facility staff provide the personal care that is needed. The three caregivers also stated would never drink in the facility and have never witnessed another caregiver drinking. The Facility Manager stated staff have been informed drinking alcohol is not allowed within the facility. Also the Facility Manager stated there has not been any complaints from the residents.

Based on LPA’s interviews conducted, the preponderance of evidence standard has not been met. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted, and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2