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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800467
Report Date: 04/19/2022
Date Signed: 04/19/2022 04:17:09 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
09/16/2020 and conducted by Evaluator Darlene Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20200916115043
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: 57DATE:
04/19/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Lisa Hulse, Vice President of OperationsTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff not providing assistance to resident.
INVESTIGATION FINDINGS:
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On 4/19/2022 at 12:45 pm, Licensing Program Analyst (LPA) Chavez initiated an unannounced complaint visit to continue the investigation on the allegation listed above. LPA met with Lisa Hulse, Vice President of Operations and explained the purpose of the visit.

On the allegation “Staff not providing assistance to resident,” the complainant’s concern was that medication staff do not assist a resident when assistance is needed. The complainant also reports that med-techs leave medication carts in resident rooms and medications for other residents in a resident’s room. To investigate the allegation, LPA interviewed the VP of Operations and staff.

Continued on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
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-AS-20200916115043
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: 04/19/2022
NARRATIVE
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On 4/19/22 at 1:00 pm, LPA spoke with Ms. Hulse who stated that Staff #1 (S1) is required to assist residents with medical concerns upon request. On 4/19/22 between 1:40 pm and 2:00 pm, LPA interviewed five residents. All five residents stated their needs are being met and have “no complaints” about how they are being treated. Two residents stated “the staff are great.” Residents interviewed stated they have never seen a medication cart in their rooms and have not witnessed any medication in their rooms besides their own.

Based on the evidence obtained, the allegation that “Staff not providing assistance to resident,” is deemed Unsubstantiated at this time. Residents interviewed state their needs are being met.

Exit interview conducted and report emailed to the administrator and Vice President of Operations.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2