405801849-9-5-2025-29-AS-KBUY-DLUNKB-20250925103139

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801849
Report Date: 09/05/2025
Date Signed: 09/05/2025 02:19:05 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
08/29/2025 and conducted by Evaluator Melisa Rankin

COMPLAINT CONTROL NUMBER: 29-AS-20250829142554

FACILITY NAME:	MYDOR'S OPEN GUEST HOMES, INC. V		FACILITY NUMBER:	405801849
ADMINISTRATOR:	AMELITA ANTONIO		FACILITY TYPE:	740
ADDRESS:	229 CORNUTA WAY		TELEPHONE:	(805) 929-8911
CITY:	NIPOMO	STATE: CA	ZIP CODE:	93444
CAPACITY:	6	CENSUS: 3	DATE:	09/05/2025
		UNANNOUNCED	TIME BEGAN:	11:32 AM
MET WITH:	Juanito Passion		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff handled resident roughly resulting in injury
Staff do not have required training for transferring residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melisa Rankin conducted an unannounced visit to initiate a complaint investigation regarding the above-mentioned allegations. LPA was accompanied by Tri-Counties Regional Center (TCRC) Quality Assurance Specialist (QAS) Miquel Magana. LPA identified themselves and met with administrator Juanito Pasion, to discuss the purpose of the visit and elements of the complaint.  

During the visit LPA collected relevant documentation, including training, physician report, staff and resident rosters, and interviewed two (2) care staff, and one (1) administrator. During the investigation LPA also conducted a phone interview and a collateral visit to a day program to interview relevant witnesses.

On the allegation: Staff handled resident roughly resulting in injury

It was alleged that on 8/15/25 Resident 1 (R1) showed a witness their arm, and a bruise was observed on R1’s left arm. The witness was told that staff had rubbed R1’s arm with a cloth and it was believed this caused R1 to have a bruise. On 8/26/25 staff was observed assisting R1 with sitting up and getting to the edge of R1’s bed, continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

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-20250829142554

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MYDOR'S OPEN GUEST HOMES, INC. V	FACILITY NUMBER: 405801849
	VISIT DATE: 09/05/2025

NARRATIVE

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it was alleged that staff grabbed R1’s left arm with staff’s right hand, and with staff’s left hand, staff grabbed the back of R1 neck and pulled R1’s head forward, pushing R1’s body forward by R1’s arm and neck, to pull R1’s body towards the end of the bed. The use of R1’s neck to move them was alleged to be forceful and unnecessary.

Interview with staff was conducted, staff demonstrated transfer assistance techniques used and discussed injury to the arm. Staff explained that injury is believed to be caused when R1 was leaning against a safety rail that is on the toilet. Staff stated that the injury resulted in a bruise, but did not state any blood was present. Staff explained that they rubbed the area where the indent and bruise occurred, stating they rubbed with their gloved hand, but did not use a cloth.

Incident reports reviewed stated that on 8/15/25 program observed the bruise to the left arm below the elbow and to the side of the arm, program stated that R1 was unclear when this happened and why there was a bruise. Incident report provided by facility stated that on 8/11/25 R1 was on the toilet for 15 minutes, when staff noticed that R1’s left elbow was learning against the safety rail and staff observed a small blister on the left lateral elbow. Images of the safety rail with a nut at the end of a screw were provided to Community Care Licensing. The screw was on the inner parts of the safety rail in the front portion of the rail, it appeared that this was part of the design of the rails, not the facilities creation. The facility also provided images of replacement toilet safety rails with no protruding attachments to ensure this did not occur again.

LPA spoke with R1, LPA also took a photo of the area where the injury occurred. A red mark in the upper/outer part of the left arm is still present. It is plausible that the injury occurred when the resident was leaning against the bar due to the position of the mark, and the location of the bold that is on the toilet safety rail. It is unclear if a cloth was used as there is conflicting information to that point. LPA observed that R1’s skin is very soft and thin, when LPA took the image of the arm. R1 has been a resident of the facility for 10 years, R1 stated to LPA and QAS that they are safe, that there was no issue with the help given during transfers, R1 stated they are able to do many movements on their own, this was confirmed with discussions done with staff at the collateral visit who stated R1 does much of the transfers to and from toileting on their own, with staff standby assist.

Based on interviews and documentation it is believed that a bruise was caused on or about 8/11/25. Based on interviews, it is unclear if the injury is due to staff rubbing the arm with a cloth, or the resident leaning against a safety rail. The allegation may have happened or is valid but there is insufficient evidence to support that, therefore, the allegation is deemed Unsubstantiated at this time.

Continued on 9099-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20250829142554

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MYDOR'S OPEN GUEST HOMES, INC. V	FACILITY NUMBER: 405801849
	VISIT DATE: 09/05/2025

NARRATIVE

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On the allegation: Staff do not have required training for transferring residents

It was alleged that on 8/26/25 it was observed that staff assisted R1 with sitting up and getting to the edge of R1’s bed, staff grabbed R1’s left arm with staff’s right hand, and with staff’s left hand, staff grabbed the back of R1 neck and pulled R1’s head forward, pushing R1’s body forward by R1’s arm and neck, to pull R1’s body towards the end of the bed. It is alleged that staff have not been trained.

LPA requested documentation of all training provided to staff regarding the positioning, transferring, and assistance used for residents. Training documents were provided, LPA noted that current staff is listed on the training dated 7/20/24. Additional transfer training is scheduled for this afternoon by a nursing consultant. Credentials and training of the consultant were reviewed by the LPA to be appropriate regarding both education and various forms of experience and skills.

LPA asked staff to show QAS and LPA how they assist and transfer R1. LPA and QAS observed staff explain their techniques. The explanation of both staff and the administrator provide that staff are aware that the neck should not be used for repositioning. The administrator stated that the consultant will come today and observe staff technique to ensure all skills are refined and reenforced.

Based on interviews, observations, and training documentation the allegation is unsubstantiated as records were provided, and the facility quickly scheduled additional training when asked by the Long-Term Care Ombudsman to ensure the confidence and safety of the resident.

Exit interview conducted and copy of the report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2025

LIC9099 (FAS) - (06/04)

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