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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800467
Report Date: 08/31/2021
Date Signed: 11/04/2021 09:43:34 AM

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
08/02/2021 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20210802152031
FACILITY NAME:GARDEN CREEKFACILITY NUMBER:
405800467
ADMINISTRATOR:KIRK P KLOTTHORFACILITY TYPE:
740
ADDRESS:73 BROAD STREETTELEPHONE:
(805) 543-2311
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:72CENSUS: DATE:
08/31/2021
UNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Lisa Hulse/AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff member did not follow COVID-19 guidelines.
INVESTIGATION FINDINGS:
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 This is an amended report. LPA De Leon is delivering amended findings for an investigation conducted by LPA Jeffries.

At 12:35pm, Licensing Program Analyst (LPA) Jeffries met with Administrator Lisa Hulse and announced the reason for the visit was to issue final findings.
As to the allegation of, “Staff member did not follow Covid-19 guidelines." On July 29, 2021, during the AM shift, facility staff 1 (S1), removed their face covering to speak to Resident 1 (R1). Based on interviews conducted and resident documentation review, R1 was hard of hearing and could not understand S1. R1 asked S1 to remove the face covering so R1 could understand S1. Per PIN 21-12-ASC issued on February 10, 2021, all staff were required to wear face coverings and all residents were advised to wear coverings when in common areas.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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 3
Control Number 29-AS-20210802152031
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: GARDEN CREEK
FACILITY NUMBER: 405800467
VISIT DATE: 08/31/2021
NARRATIVE
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PIN 21-12-ASC provides exemptions to mask/face covering requirements per the California Department of Public Health (CDPH). CDPH lists a person communicating with a person who is hearing impaired, where the ability to see the mouth is essential for communication, would be exempt from wearing the mask.
Therefore, the allegation of, “Staff member did not follow COVID-19 guidelines” is unsubstantiated at this time.

Exit interview, report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210802152031
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: GARDEN CREEK
FACILITY NUMBER: 405800467
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
CCR
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Deficiency has been amended, no deficiency cited at this time.
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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: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3