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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425801497
Report Date: 07/31/2023
Date Signed: 07/31/2023 11:16:35 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
06/01/2023 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20230601142856
FACILITY NAME:AMALIA'S RESIDENCEFACILITY NUMBER:
425801497
ADMINISTRATOR:DEXTER PRICEFACILITY TYPE:
740
ADDRESS:1002 GUNNER STREETTELEPHONE:
(805) 922-5475
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: 6DATE:
07/31/2023
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Dexter Price, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff violated resident’s personal rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA conducted the 10 day visit and requested relevant documents on 6/1/23. LPA interviewed reporting party, residents, Administrator on 6/1/23, and 6/19/23 and Staff 1 on 6/15/23. LPA Olson met with Dexter Price, Administrator and explained the purpose of the visit.

On the allegation: Staff violated resident’s personal rights. It was alleged that Staff 1 (S1) rudely said to a resident “why didn’t you plan this thing out at a better time, why didn’t you go poop earlier?” LPA interviewed residents, who stated S1 is very rude, things have to be on S1’s time, and everyone has to do what S1 wants. Multiple residents interviewed indicated S1 tried to force another resident to cut their hair when the resident did not want to, and it made some residents uncomfortable. Residents stated S1 “has an attitude, is really bossy, wants things [S1’s] way, takes control and tells us what to do. [S1] tries to run our life…” and will get in your face if really mad. Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
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-20230601142856
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: AMALIA'S RESIDENCE
FACILITY NUMBER: 425801497
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2023
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly 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:
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Licensee agreed to schedule training for all staff on personal rights by 7/31/23, and submit proof of training to CCL.
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Based on interviews, the licensee did not comply with the section cited above when Staff 1 (S1) did not speak to residents with dignity which was 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: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20230601142856
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: AMALIA'S RESIDENCE
FACILITY NUMBER: 425801497
VISIT DATE: 07/31/2023
NARRATIVE
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LPA interviewed S1, who admitted that they may have gone too far in verbally pushing residents. S1 stated they really care for the residents, including R1, and they remind them of their father and they treat R1 like they do their father. S1 stated their father is in a home and needs reminders and to be told to do things but they realize R1 is not their father and they may need to stop treating them like their father. Based on the information obtained. The allegation is deemed Substantiated at this time.

Exit interview conducted, copy of report, deficiencies and appeal rights issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
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
06/01/2023 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20230601142856

FACILITY NAME:AMALIA'S RESIDENCEFACILITY NUMBER:
425801497
ADMINISTRATOR:DEXTER PRICEFACILITY TYPE:
740
ADDRESS:1002 GUNNER STREETTELEPHONE:
(805) 922-5475
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: DATE:
07/31/2023
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff not allowing resident to schedule their own medical appointments
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegations above. LPA conducted the 10 day visit and requested relevant documents on 6/1/23. LPA interviewed reporting party, residents, and Administrator on 6/1/23. LPA Olson met with Dexter Price, Administrator and explained the purpose of the visit.

On the allegation: Staff not allowing resident to schedule their own medical appointments. It was alleged that staff canceled a resident’s Physical Therapy (PT) and Occupational Therapy (OT) appointments. The Reporting Party (RP) stated the PT and OT nurses disclosed that Staff 1 (S1) has been rescheduling their appointments. RP states R1 used to make their own appointments, but S1 is having PT and OT contact them to schedule the appointments. RP stated R1 is capable of scheduling their own appointments. LPA interviewed Administrator who stated that R1 gets mixed up and was scheduling OT and PT appointments during their dialysis treatment and recently gave staff the wrong time for their doctor appointment.
Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
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-20230601142856
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: AMALIA'S RESIDENCE
FACILITY NUMBER: 425801497
VISIT DATE: 07/31/2023
NARRATIVE
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The doctor’s office was confused why the Administrator didn’t bring R1 at the correct time. Administrator stated R1 is refusing to allow staff to communicate to the doctor’s office, OT and PT but they need to be able to communicate to confirm the time of appointment and possibly reschedule if there are conflicts with transportation arrangements or other appointments. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5