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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850052
Report Date: 10/07/2024
Date Signed: 10/07/2024 09:51:48 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
12/27/2023 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20231227101251
FACILITY NAME:PARK PLACE ASSISTED LIVINGFACILITY NUMBER:
405850052
ADMINISTRATOR:BARNHILL, DIANAFACILITY TYPE:
740
ADDRESS:7500 PORTOLA RDTELEPHONE:
(805) 591-9855
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:13CENSUS: 10DATE:
10/07/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:BOM, Letica Ruiz-GuerreroTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility did not give a resident sufficient notice of rate increases.
Facility is not following a resident's care plan.
INVESTIGATION FINDINGS:
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 At 9:30am on10/07/2024, Licensing Program Analyst (LPA) Jeffries conducted a subsequent complaint visit to issue final findings on this investigation. LPA met with BOM, Letica Ruiz-Guerrero and explained the purpose of the visit. During the investigation, LPA De Leon conducted an initial visit on 12/28/2023 from 12:30pm to 2:10pm, where LPA interviewed staff and residents and requested documents. LPA conducted additional resident and staff interviews on 7/22/2024 from 10:15am to 3:15pm on another complaint with a similar allegation. Additional interviews with witness, Administrator and staff were conducted on 10/3/2024.

On the allegation: Facility did not give a resident sufficient notice of rate increases. It was alleged R1 was not given proper 60 days written notice for the increase, as the notice was provided 11/20/2023, less than 60 days before 1/1/2024. In August 2023, R1’s rent was originally $7000 per month. LPA reviewed a text message dated 11/21/2023 from the Administrator to R1’s responsible party stating they would be sending a 2-day notice “by Monday” that includes a rate increase to add a second overnight staff to provide supervision at a cost of $4880 per month. CONTINUED on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2024
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 6
Control Number 29-AS-20231227101251
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: PARK PLACE ASSISTED LIVING
FACILITY NUMBER: 405850052
VISIT DATE: 10/07/2024
NARRATIVE
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The texts states it will be a second fulltime staff to supervise R1 between 10pm to 6am. The text states the increase would start 2 days after receiving the notice. The text states November would be prorated, December’s rent would be $11,880 (the original $7000 rent plus the one on one fee), and starting 1/1/2024 it would be $13,068 per month. The written rate increase notice reviewed, dated 11/20/2023, states the rate as of 12/1/2023 would be $11,800 per month and as of 1/1/2024 would be $12,980 due to a 10% increase. Based on the information, the facility did not give sufficient notice of rate increases for January 2024. Another concern brought forth was that the facility wanted to increase R1’s rent starting in January by more than 10%. However, Title 22 regulations and health and safety code currently do not have increase caps for RCFEs. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegation: Facility is not following a resident's care plan. It was alleged that R1 required a one-on-one staff overnight for wandering behavior, so the facility increased R1’s monthly fee in order to provide additional staff in the facility. However, it was alleged the facility did not provide additional staff following the rate increase. A witness stated they did a “stakeout” at the facility from 10pm to 6am and did not see any additional staff go into the facility.
LPA reviewed a text message dated 11/21/2023 from the Administrator to R1’s responsible party stating they would be sending a 2-day notice that includes a rate increase to add a second overnight staff to provide supervision at a cost of $4880 per month. The texts states it will be a second fulltime staff to supervise R1 between 10pm to 6am. The written increase states an additional $4800 would be added for “one on one supervision.”

Administrator stated R1 was very aggressive and was up most of the night and would go through the kitchen refrigerator and pantry, and had other aggressive behaviors. Administrator stated the one NOC staff could not attend to round on the other residents and properly supervise R1, so they added an extra staff overnight. Administrator stated typically the PM shift stayed an extra 1-2 hours to help the NOC staff, and then Administrator came in around 11pm-12am and stayed until 4-5am after R1 went to bed. Administrator stated R1 did not need a one on one to watch them every second, but rather they just needed a second staff overnight to provide adequate supervision to R1.

CONTINUED on LIC9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20231227101251
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: PARK PLACE ASSISTED LIVING
FACILITY NUMBER: 405850052
VISIT DATE: 10/07/2024
NARRATIVE
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Facility charting notes for December 2023 were reviewed. There were notes from the AM and NOC shifts. NOC shift notes stated on 12/19/2023, R1 was up when the staff got to work, but went to bed at 12:30am and stayed asleep. On 12/20/2023, the notes state R1 came out of their room at 10:45pm to eat dinner, went back to their room at 2am and stayed there. On 12/21/2023, the notes state R1 came out of their room around 10pm and 10:20pm looking for a particular staff. R1 went to their room but kept coming out all night. On 12/22/2023, the notes state R1 was awake when they got to work but went to bed at 11:30pm and stayed asleep. On 12/24/2023, the notes state R1 stayed awake, came out of their room to eat again, and went to sleep at 2am and stayed asleep. Based on the investigation, the written two-day increase for R1 states specifically “one on one supervision,” which was not provided based on Administrator’s interview. Therefore this allegation is deemed Substantiated at this time.

Exit interview, deficiencies cited on 9099-D, report given, appeal rights given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
12/27/2023 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20231227101251

FACILITY NAME:PARK PLACE ASSISTED LIVINGFACILITY NUMBER:
405850052
ADMINISTRATOR:BARNHILL, DIANAFACILITY TYPE:
740
ADDRESS:7500 PORTOLA RDTELEPHONE:
(805) 591-9855
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:13CENSUS: 10DATE:
10/07/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:BOM, Letica Ruiz-Guerreroand TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility is overcharging a resident for services.
Facility staff yell at residents.
Facility staff did not ensure that a resident's clothing was free of stains.
INVESTIGATION FINDINGS:
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 At 9:30am in 10/07/2024, Licensing Program Analyst (LPA) Jeffries, conducted a subsequent complaint visit to issue final findings on this inestigation. LPA met with BOM, Letica Ruiz-Guerreroand and explained the purpose of the visit. During the investigation, LPA De Leon conducted an initial visit on 12/28/2023 from 12:30pm to 2:10pm, where LPA interviewed staff and residents and requested documents. LPA conducted additional resident and staff interviews on 7/22/2024 from 10:15am to 3:15pm on another complaint with a similar allegation. Additional interviews with witness, Administrator and staff were conducted on 10/3/2024.

On the allegation: Facility is overcharging a resident for services. It was alleged the facility was directly charging for medications picked up from the pharmacy and for briefs, even though insurance would have paid for these items. R1’s responsible party stated they informed the Administrator on 8/5/2023 that R1 can get their medications for free through the military, and instructed the Administrator to go through the military to get the medications. R1’s responsible party wrote a check for $55.42 on 8/5/2023 for medications. CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20231227101251
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: PARK PLACE ASSISTED LIVING
FACILITY NUMBER: 405850052
VISIT DATE: 10/07/2024
NARRATIVE
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 On 8/25/2023 they were invoiced for a medication that was $33.97, and wrote a check on 9/2/2023. On 10/1/2023 they wrote a check to cover medication gummies at $27.93 and briefs at $44.50. Administrator confirmed R1’s responsible party did state the VA would pay for the medications and briefs, however the Administrator stated they were unable to access the VA. Administrator stated they told R1’s responsible party that as their responsible party/POA they could access the VA on R1’s behalf and provide the items. However the items were never provided, so Administrator purchased the items for reimbursement to ensure R1 had the medication and care items they needed. Although, the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.
On the allegation: Facility staff yell at residents. It was alleged a staff yelled at a resident they were not getting any lunch. Multiple residents interviewed stated they were treated “fine,” “well,” “very well,” and said there was no yelling or disrespect. One resident stated a staff was disrespectful. Staff stated they never yell at residents, and treat residents with respect. Administrator stated staff have never yelled or been disrespectful, and they would not tolerate that behavior from staff. A credible witness was interviewed who stated they had never witnessed or heard of staff yelling at the residents, but had consistently heard and/or witnessed staff are rude or mean to residents. Witness indicated one resident stated some staff are kinder than others. Administrator stated one resident does not want to be at the facility so they complain about a lot of things. Based on the information obtained, this allegation is deemed Unsubstantiated at this time, and staff’s disrespectful behavior will be addressed on complaint 29-AS-20240715084408.
On the allegation: Facility staff did not ensure that a resident's clothing was free of stains. It was alleged R1 spilled food on a new jacket, and it had not been washed but R1 continued to wear the jacket. Administrator confirmed that R1 had very aggressive behaviors, and often refused care verbally and by hitting and kicking staff. Administrator stated R1 had one jacket and wore it often. Administrator stated they tried to wash the jacket but R1 would refuse to allow staff to take it off or launder it, in similar way that R1 refused showers. One time, R1 went outside in the heat and removed their jacket and left it on the patio, so the housekeeper took it and washed it. A credible witness interviewed stated they have not heard of any issues regarding laundry, and have not observed any stained clothes. Administrator stated R1’s behaviors were conveyed to R1’s responsible party. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview, report given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20231227101251
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: PARK PLACE ASSISTED LIVING
FACILITY NUMBER: 405850052
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2024
Section Cited
HSC
1569,655(a)
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1569.655(a)…the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs…This requirement is not met as evidenced by:
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POC: Administrator agrees to submit a written statement of acknowledgement and understanding of 1569.655 by 10/21/2024.
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Based on interviews and record review, the licensee did not comply with the section cited above when they issued a general rate increase with less than 60 days notice, which posed a potential personal rights risk to residents in care.
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Type B
10/21/2024
Section Cited
CCR
87507(e)
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87507(f) Admission Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by:Based on interviews, the licensee did not comply with the section
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POC: Administrator agrees to refund R1’s one on one care charges, since one on one care was not provided. Administrator will send proof by 10/21/2024.
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cited when they stated in writing R1 would have one on one care and did not provide it, which posed a potential 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: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6