<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405802295
Report Date: 04/22/2025
Date Signed: 04/22/2025 04:52:00 PM

Substantiated


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
04/21/2025 and conducted by Evaluator Garrett Haner-Tomasko
COMPLAINT CONTROL NUMBER: 29-AS-20250421084939
FACILITY NAME:RESIDENCE IV, THEFACILITY NUMBER:
405802295
ADMINISTRATOR:MARCOS, MEYNARDFACILITY TYPE:
740
ADDRESS:347 CALLE LUPITATELEPHONE:
(805) 549-0328
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:6CENSUS: 6DATE:
04/22/2025
UNANNOUNCEDTIME BEGAN:
08:16 AM
MET WITH:Licensee/Administrator - Meynard MarcosTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff yell at residents
Staff do not speak to residents with dignity and respect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/22/2025 at 08:16am Licensing Program Analyst (LPA) Haner-Tomasko arrived unannounced at the facility to investigate the allegations to this complaint and conduct an annual facility inspection. LPA met with Licensee Meynard Marcos and explained the purpose of the visit.

During the visit, LPA interviewed staff, clients, licensee, and obtained relevant documents.

On the allegations: Staff yell at residents and staff do not speak to residents with dignity and respect. It was alleged Staff 1 (S1) aggressively speaks to the residents, yelling at residents several times within a few minutes, and telling them repeatedly to sit down. Interviews revealed S1 will speak with a raised voice to residents and commandingly tell residents to sit down repeatedly. Based on the information obtained, the allegations are deemed Substantiated at this time.

Exit interview, deficiencies cited on 9099-D, copy of report given, appeal rights given.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
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 2
Control Number 29-AS-20250421084939
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: RESIDENCE IV, THE
FACILITY NUMBER: 405802295
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2025
Section Cited
CCR
87468.1(a)(1)
1
2
3
4
5
6
7
(a)Residents... shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to train all staff on Residents Personal Rights and email LPA a signed roster of staff who participated in the training and any documents reviewed at the training by 05/06/2025.
8
9
10
11
12
13
14
Based on interviews, the licensee did not comply with the section cited above when S1 raised their voice commandingly at the residents and repeatedly commanded them to sit down.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2