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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425800674
Report Date: 03/21/2022
Date Signed: 03/21/2022 02:31:11 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
03/17/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220317103540
FACILITY NAME:MYDOR'S OPEN GUEST HOME, INC. IFACILITY NUMBER:
425800674
ADMINISTRATOR:AMELITA ANTONIOFACILITY TYPE:
740
ADDRESS:742 E. MC ELHANY AVE.TELEPHONE:
(805) 922-0412
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 6DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Amelita Antonio, AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Staff denied a resident from having a cane while in care
Staff do not have planned activities for a resident while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an initial complaint visit to the facility above. LPA met with Amelita Antonio, Administrator and explained the purpose of the visit. LPA was accompanied by Tri-Counties Regional Center Quality Assurance Specialist (QAS) Vincent Figueroa. LPA interviewed staff and residents on 3/21/22 at 12:20, 1:03, and 1:40 PM.

On the allegation: Staff denied a resident from having a cane while in care. Administrator stated to LPA, QAS, and a credible witness that Resident 1 (R1)’s cane was taken away because R1 used it to hit staff. R1 denied hitting staff with the cane to the credible witness yet admitted to LPA and QAS that he hits people with it when upset. Interviews LPA conducted revealed that administrator stated they discussed the behaviors with Service Coordinator and R1’s Doctor but could have done more to correct the behavior instead of taking the cane away. Based on the information obtained, the allegation is substantiated.

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

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
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-20220317103540
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: MYDOR'S OPEN GUEST HOME, INC. I
FACILITY NUMBER: 425800674
VISIT DATE: 03/21/2022
NARRATIVE
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On the allegation: Staff do not have planned activities for a resident while in care, R1 reported to a credible witness that R1 has not been allowed outside of the home, including the backyard and patio. Interviews revealed the last time an activity was planned outside with residents was 2/14/22. Based on the information obtained, the allegation is substantiated.

Exit interview, deficiencies cited on 9099-D, report emailed, appeal rights emailed to Administrator/Licensee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20220317103540
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: MYDOR'S OPEN GUEST HOME, INC. I
FACILITY NUMBER: 425800674
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/21/2022
Section Cited
CCR
87468.1(a)(12)
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To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money. This requiment is not met as evidence by...
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Administrator agreed to create a plan to ensure R1 can use a cane when needed and behavior is addressed by other means and submit the plan to CCL by 3/28/22.
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Based on interview and record review, the licencee did not allow R1 to keep their own cane, which violated the residents personal rights.
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Type B
03/21/2022
Section Cited
CCR
87219(a)(6)
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A planned activities program which includes social and recreational activities appropriate to the interests and capabilities of the resident...This requiment is not met as evidence by...
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Administrator agreed to plan activiites outside once to twice a week and submit a calendar of activites to CCL by 3/28/22.
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Based on interview and record review, the licencee did not allow R1 to go outside which violated the residents personal rights.
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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: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3