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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850478
Report Date: 09/16/2021
Date Signed: 09/16/2021 04:33:34 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
09/14/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210914163933
FACILITY NAME:YOKAM'S RCFE # 1NFACILITY NUMBER:
405850478
ADMINISTRATOR:KAMTO, YOLANDE KONGUEPFACILITY TYPE:
740
ADDRESS:170 S. MESA RDTELEPHONE:
(805) 619-7615
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:6CENSUS: 2DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Cheryll Y Estacio, Back-up to AdministratorTIME COMPLETED:
01:31 PM
ALLEGATION(S):
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Staff member was not wearing a mask.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10-day Complaint visit to the facility above. LPA met with back-up to the Administrator Cheryll Estacio and explained the purpose of the visit.

LPA took tour of the facility with Staff. LPA reviewed 2 reisdents LIC 602's and interviewed Staff 1 (S1) and Staff 2 (S2). Requested and received LIC 500 staff roster.

On the alegation: Staff member was not wearing a mask. LPA interviewed credible witness and staff regarding the allegation. S2 stated on 09/08/2021 the door bell rang and S2 answered the door without the mask pulled up over S2 nose and mouth. S2 stated they then pulled up the mask and addressed the vistor.
Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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 5
Control Number 29-AS-20210914163933
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: YOKAM'S RCFE # 1N
FACILITY NUMBER: 405850478
VISIT DATE: 09/16/2021
NARRATIVE
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 Witness 1 (W1) stated W1 knocked on door and the staff answered the door not wearing a mask. Based on evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights emailed to Licensee/Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20210914163933
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: YOKAM'S RCFE # 1N
FACILITY NUMBER: 405850478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents...: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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Administrator agreed to hold infectious control trianing, review and train staff on PIN 21-38-ASC with all staff regarding masks wearing in the facility provide copy of trianing and staff signatures to CCL.
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Based on interviews with W1 and S2 the licensee did not comply with regulation above due to S2 answered the door without a mask on which poses an immediate health and safety risk to reisdents 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: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
09/14/2021 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20210914163933

FACILITY NAME:YOKAM'S RCFE # 1NFACILITY NUMBER:
405850478
ADMINISTRATOR:KAMTO, YOLANDE KONGUEPFACILITY TYPE:
740
ADDRESS:170 S. MESA RDTELEPHONE:
(805) 619-7615
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY:6CENSUS: 2DATE:
09/16/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Cheryll Y Estacio, Back-up to AdministratorTIME COMPLETED:
01:31 PM
ALLEGATION(S):
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9
Medications are not stored in a safe and secured location.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10-day Complaint visit to the facility above. LPA met with back-up to the Administrator Cheryll Estacio and explained the purpose of the visit.

LPA took tour of the facility with Staff. LPA reviewed 2 residents LIC 602's and interviewed Staff 1 (S1) and Staff 2 (S2).

On the allegation: Medications are not stored in a safe and secured location. LPA interviewed Staff 1 (S1) and Saff 2 (S2) and both staff stated medication is kept in locked file cabinets in the office. LPA observed medications to be locked in the office file cabinets. R1 has personal grooming and hygiene items at bedside that are not a risk to R1 based on the LIC 602 Physicians report section 14 j.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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 5
Control Number 29-AS-20210914163933
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: YOKAM'S RCFE # 1N
FACILITY NUMBER: 405850478
VISIT DATE: 09/16/2021
NARRATIVE
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 Residents are non-ambulatory and can not get up without assistance from staff.
LPA explained that centrally stored medication needs to be kept locked and based on a residents LIC. 602 Physicians report if the box 14 j is marked YES then residents would need those items to be inaccessible. S2's interview revealed that S2 had medications out in the office on 09/08/2021 to prepare for residents when their was a knock on the door S2 answered the door leaving the medications in the office. Residents were in their rooms, are non-ambulatory and did not have access to the medications. Based on the evidence in this allegation it is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report emailed to Administrator/Licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5