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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405801856
Report Date: 04/06/2022
Date Signed: 04/06/2022 01:24:01 PM

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
04/01/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220401105621
FACILITY NAME:A HEAVENLY HOME, LLCFACILITY NUMBER:
405801856
ADMINISTRATOR:JENNIFER R. JIMENEZFACILITY TYPE:
740
ADDRESS:1920 PROSPECT AVENUETELEPHONE:
(805) 296-3239
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY:6CENSUS: 5DATE:
04/06/2022
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Karla Sanchez, AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Masking protocols are not being followed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced 10-day complaint investigation visit to the facility above.

LPA entered the facility at 12:15 PM and observed staff with mask not properly covering their nose. After opening the door staff pulled up their mask to properly cover their nose. A minute later a second staff entered through the back door with mask around their chin and waited to put it on properly until they stepped inside of the facility. LPA spoke with Administrator Jennifer Jimnez over the telephone and explained the purpose of the visit. Administrator sent Karla Sanchez who is a backup administor to the facility. LPA explained the purpose of the visit and toured the facility with Karla at 12:30PM.

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

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
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-20220401105621
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: A HEAVENLY HOME, LLC
FACILITY NUMBER: 405801856
VISIT DATE: 04/06/2022
NARRATIVE
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LPA interviewed staff regarding the allegation. Administrator interview revealed that staff always wear masks in the facility. Administrator stated over the phone that after the witness reported staff was not wearing a mask the staff was given a write up and masks were immediately brought over. Staff 1 (S1) stated that most staff have a mask on them but need reminders to wear it properly. S1 stated that there is proper PPE in multiple places throughout the facility. Staff 2 (S2) stated that they were aware of the masking policies and where masks were located.

A credible witness (W1) stated on 3/30/2022, W1 observed a staff who was not wearing a mask and staff stated to them that there were no masks in the facility. LPA interviews revealed that in fact there were masks in the facility but in a location they were not aware of. Administrator Karla stated that when staff clock in there are always masks there in the office and they were in stock that day.

Based on LPA observation, interviews, and the credible witness statement this allegation is deemed Substantiated at this time.

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: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220401105621
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: A HEAVENLY HOME, LLC
FACILITY NUMBER: 405801856
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2022
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 4/7/2022.
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Based on credible witness and LPA 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: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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