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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405800923
Report Date: 04/11/2025
Date Signed: 04/11/2025 08:57:58 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
04/10/2025 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20250410114231
FACILITY NAME:SOUTHBAY MAXI CAREFACILITY NUMBER:
405800923
ADMINISTRATOR:LITA C. LAZOFACILITY TYPE:
740
ADDRESS:1410 13TH STREETTELEPHONE:
(805) 528-1725
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY:6CENSUS: 4DATE:
04/11/2025
UNANNOUNCEDTIME BEGAN:
07:17 AM
MET WITH:Administrator Lida LazoTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Licensee did not ensure residents were provided food of good quality.
INVESTIGATION FINDINGS:
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 At 7:30am on 04/11/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the initial investigation visit to the allegation to this complaint. LPA met with Administrator, Lita Lazo announce who he is and the reason for the visit. LPA conducted interviews, conducted a physical tour of the facility focusing on the kitchen and food supply. LPA made observations and took photographs. LPA requested documentation to support the final finding of the allegation to this complaint that were issued on this visit.
As to the allegation of, “Licensee did not ensure residents were provided food of good quality.” It was alleged that in the late morning of 04/08/2025, a reliable witness (a person with license or credentials indicating expertise training and/or experience) observed, “a handful of rotting, shriveled carrots with brown spots and one rotting squash.” a photograph of said vegetables was provided. It was discovered on 04/11/2025 that Licensing Program Analyst (LPA) Jeffries conducted an interview with Administrator Lida Lazo (S1) on 04/11/2025, who stated, "need to clean the kitchen refrigerator/(frezer) of all bad food."
CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
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-20250410114231
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: SOUTHBAY MAXI CARE
FACILITY NUMBER: 405800923
VISIT DATE: 04/11/2025
NARRATIVE
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On 04/11/2025 LPA Jeffries observed undistinguishable fruit (could have been Pears or Apples) that were in a plastic bag and rotting. LPA observed a full container of Sprouts Organic Vanilla Oatmilk with a sale date of 06/21/2023 that were in the kitchen refrigerator; LPA observed several frozen meats with sell by dates that were over 1 year old in the kitchen freezer. Based on a reliable W1 observation and photographs, LPAs observation, photographs and interviews there is enough evidence at this time to support the allegation of, “Licensee did not ensure residents were provided food of good quality.” And is substantiated at this time.

Exit interview, report read, citation issued, appeal rights and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250410114231
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: SOUTHBAY MAXI CARE
FACILITY NUMBER: 405800923
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2025
Section Cited
CCR
87555(b)(8)(9)
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87555 General Food Service...(b) The following food service requirements shall apply...(8)All food shall be of good quality...Food in damaged containers shall not be accepted, used or retained.(9) Procedures which protect the safety, acceptability and nutritive values of food
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licensee Lida Lazo will inventory every food item is the kitchen refrigerator/freezer and discard all food with dates older than 2024 on the sell by tag, all foods damaged and or rotting and provided covered container for all loose foods. Administrator will email or text
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 shall be observed in food storage, preparation and service. This requirement was not met by evidence of W1 observations/photographs and LPA's observation and photographs, which puts residents in potential danger.
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pictures of refrigerator/frezzier once per for the next 4 weeks to ensure quality food has replaced discarded food. Admin. will also provide grocery receipts for the next 4 weeks by email or photo text to LPA.
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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: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC9099 (FAS) - (06/04)
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