425801823-6-15-2023-29-AS-KBUY-CT7Q9M-20230627115834

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801823
Report Date: 06/15/2023
Date Signed: 06/15/2023 01:26:33 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
03/27/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230327143913

FACILITY NAME:	AMALIA'S RESIDENCE II		FACILITY NUMBER:	425801823
ADMINISTRATOR:	DEXTER PRICE		FACILITY TYPE:	740
ADDRESS:	1206 KENSINGTON AVENUE		TELEPHONE:	(805) 287-9630
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS: 6	DATE:	06/15/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Amalia Ilaban, Staff		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff denied resident visitors

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA Chavez conducted the 10 day visit and requested relevant documents on 4/3/23. LPA Olson interviewed reporting party on 3/28/23, Administrator on 4/4/23 and 5/4/23, and witnesses on 3/27/23, 3/28/23, 4/20/23, and 4/24/23. LPA Olson met with Staff and explained the purpose of the visit.

On the allegation: Staff denied resident visitors. It was alleged that on 1/1/23, a visitor was denied access to visit Resident 1 (R1). Interviews with Administrator revealed that they were told by APS and the police that due to the visitor’s behavior and the incident that occurred on 10/5/22, the visitor was banned from the facility. Administrator stated APS directly told the visitor they were not allowed to come back and the visitor didn’t come back for 3 months, so they thought they were able to not allow them to visit.
Contiuned on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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 4

Control Number 29-AS-20230327143913

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 II	FACILITY NUMBER: 425801823
	VISIT DATE: 06/15/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

According to the Administrator, the visitor came on 1/1/23 with an “intimidating” friend who was over 6 feet tall and the Administrator stated they tried to force their way in to the facility, and were yelling and using racist remarks towards the Administrator and staff. Administrator stated they did not feel safe or comfortable letting them in. Administrator was also concerned that the visitor, who was not R1’s POA, may try to take R1 out of the facility again or may abuse R1, as had been concluded by APS in the past. LPA advised the Administrator that they should have called 911 if they felt threatened, and the only way to restrict visitation is to get a restraining order. Administrator filed for a restraining order against this visitor, and the temporary restraining order was granted. Based on the information obtained, the allegation is deemed Substantiated at this time. A technical Violation was issued.

Exit interview conducted, copy of report and appeal rights were printed and emailed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
03/27/2023 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20230327143913

FACILITY NAME:	AMALIA'S RESIDENCE II		FACILITY NUMBER:	425801823
ADMINISTRATOR:	DEXTER PRICE		FACILITY TYPE:	740
ADDRESS:	1206 KENSINGTON AVENUE		TELEPHONE:	(805) 287-9630
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS:	DATE:	06/15/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:			TIME COMPLETED:	01:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained bruises due to staff handling resident roughly

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Olson conducted an unannounced subsequent complaint visit to issue final findings on the allegation above. LPA Chavez conducted the 10 day visit and requested relevant documents on 4/3/23. LPA Olson interviewed reporting party on 3/28/23, Administrator on 4/4/23 and 5/4/23, witnesses on 3/27/23, 3/28/23, 4/20/23, and 4/24/23, and residents on 6/15/23. LPA Olson met with Staf and explained the purpose of the visit.

On the allegation: Resident sustained bruises due to staff handling resident roughly. On 3/27/23 CCL received a complaint alleging Resident 1 (R1) has been abused by staff since October 5, 2022 and reporting party has it on video. Reporting party stated R1 has bruises covering 90% of their hands, wrists, and forearms, as well as across their chest. Reporting party stated they called the police on 10/5/22 and police went to the facility to check. Reporting party stated the staff told the police nothing was wrong with R1 and they left. Reporting party stated they went to take R1 out of the facility but were denied because R1 had a different POA who was in charge of R1’s living arrangements. Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20230327143913

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 II	FACILITY NUMBER: 425801823
	VISIT DATE: 06/15/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

RP stated they had a video of R1 begging and pleading to leave with RP and R1 grabbing onto the staircase banister due to staff roughly taking R1 back to their room.

LPA reviewed facility incident report that states on 10/5/22 R1 became agitated when a visitor came to the facility asking R1 for money and then demanding to take R1 out of the facility. 911 was called and R1 went to the ER to get checked out, the facility also contacted APS. The resident was discharged with a UTI and put on antibiotics. LPA interviewed Ombudsman who stated they visit the facility once a month and routinely check for bruises and signs of abuse. Ombudsman stated they have not seen any suspicious bruises on any residents. LPA interviewed APS, who indicated they had received reports of abuse between R1 and their visitor, and did not refer the case to CCL because there was no indication of facility abuse towards R1. LPA reviewed hospice notes from R1 which did not indicate any bruising or concerns about rough handling. LPA Chavez observed R1 on 4/3/23 but could not observe bruises on R1 because R1 was covered in a blanket and sleeping. LPA Olson observed the video footage from reporting party and observed a few bruises on R1’s hand, on the very tops of R1’s hand. There were no bruises visible on the arms or wrists. LPA interviewed Administrator, who indicated R1 had bruises on their hand after the visitor visited R1. However, Administrator noted the bruises stopped after the visitor stopped visiting R1. R1’s physician’s report dated 9/2/22 indicates they have diagnoses of dementia, agitation, TIA, anxiety, and incontinence. LPA reviewed additional portions of the video filmed by the visitor. The video shows the visitor asking R1 leading questions and guiding them to a specific answer. The visitor gets R1 to indicate the staff are “mean” and the bruises are from the staff. The visitor tells R1 that their POA is “killing” them, and that the visitor could not obtain money because of the POA. LPA interviewed the other residents at the facility. Residents indicated the staff were nice, met their needs, and did not hurt them or handle them in a rough manner. LPA also did not observe any bruises on residents hands, arms or wrists. Based on the information obtained, there is insufficient evidence to prove that staff roughly handled R1 leading to bruising. Therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of report emailed and printed.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Jeannette Olson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4