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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800467
Report Date: 04/14/2022
Date Signed: 04/14/2022 11:26:04 AM

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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/08/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220408102431
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:
04/14/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lisa Hulse, Backup AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility staff not properly wearing mask
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced 10-day complaint investigation visit to the facility above. LPA met with Lisa Hulse, Backup Administrator, and explained the purpose of the visit.

LPA toured the facility and witnessed 8/8 staff properly wearing their masks. LPA interviewed staff and residents regarding the allegation. Staff (S1) interview revealed the facility staff always wear masks in the facility. Resident 1 (R1) interview stated the staff are always wearing masks in the facility. A credible witness (W1) stated on 3/29/2022, W1 observed a male staff in the kitchen washing dishes with his mask below his mouth and nose. Another female staff member was seen on the second floor with her mask below her nose. W1 also observed a female housekeeping staff member with a mask below the nose and mouth, talking in the front desk reception area while a large group event was taking place in the main living area. Based on credible witness statement, this allegation is deemed Substantiated at this time.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
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 29-AS-20220408102431
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: 04/14/2022
NARRATIVE
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The facility failed to protect the personal rights of residents in care to be able to receive safe and healthful accommodations, in that the facility staff failed to wear face coverings properly while providing care and supervision to residents in care. This is a violation of official government orders requiring the wearing of face coverings while working under specified conditions.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Licensee/Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220408102431
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: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/14/2022
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities
...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator has agreed to immediately notify all staff to wear masks at all times in the facility. Administrator agreed to hold training with all staff about proper mask-wearing and COVID-19 prevention protocol, and provide training records to CCL by 4/15/2022.
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Based on credible witness observation, the licensee did not ensure staff were wearing face masks in 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: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3