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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850021
Report Date: 04/09/2021
Date Signed: 07/09/2021 12:49:37 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
04/01/2021 and conducted by Evaluator Arien Diaz
COMPLAINT CONTROL NUMBER: 29-AS-20210401162329
FACILITY NAME:LORIE'S RCFE LLC #3FACILITY NUMBER:
425850021
ADMINISTRATOR:ROBLES, FREDAFACILITY TYPE:
740
ADDRESS:1017 E SUGAR BUSH DRTELEPHONE:
(805) 922-9525
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:6CENSUS: 3DATE:
04/09/2021
UNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Lorie Valdez, AdministratorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not ensure facility was free from insects
INVESTIGATION FINDINGS:
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This is an amended report. Licensing Program Analyst (LPA) Chavez conducted a visit to the facility to deliver final findings of a complaint investigated by LPA Diaz. On the allegation: Staff did not ensure facility was free from insects. LPA Diaz reviewed facility documents and conducted interviews with staff, a credible witness and a family member. LPA interviewed staff on 6/3/21 at 2:38pm; on 6/4/21 at 3:56pm; on 6/7/21 at 10:25am, 2:45pm and at 4:00pm; on 6/8/21 at 11:55am; and on 6/9/21 at 2:45pm. LPA interviewed Resident 1’s (R1’s) family member on 6/8/21 at 4:15pm. LPA interviewed a credible witness on 4/7/21 at 9:53am. According to the Administrator, in the month of March 2021, a family member saw ants near R1’s bedroom door entrance. S1 inspected the backyard of the facility and saw 7 ants on R1’s outside door. The family member confirmed with the LPA that they saw ants on the floor near the entrance of R1’s bedroom door. On 3/23/21 the Administrator had maintenance spray the exterior of the facility, and pest control inspect the facility. The Pest Control Operator observed a singular trail of ants in a space of 15 feet outside. Pest Control applied Termendor, a non-repellent chemical in the ant nest outside the facility. Pest control also baited the interior of the facility and around the sinks for precaution. In addition, facility maintenance staff purchased insecticide on 4/1/21 and sprayed it to exterior according to the licensee. The licensee stated that the witness arrived at the facility on 3/31/21 and told Staff 2 (S2) that ants were at the foot of R1’s bed and on R1’s pillow. The witness confirmed on 3/31/21 they saw three ants on R1’s pillow, and near R1’s feet and saw over twenty ants moving on and underneath R1’s chuck pad. The credible witness notified S2, and S2 acknowledged there were ants in R1s bed. The credible witness stated they killed and swiped away many ants from the bed. According to an interview with S2, S2 entered R1’s room and saw 3 ants at the foot of the bed, and 1 ant on R1’s pillow. The credible witness asked S2 to change the bedsheets but S2 needed help from Staff 3 (S3). Interviews with S3 and S4 revealed S2 informed them about the ants in R1’s room. S2 told S3 and S4 that the credible witness saw lots of ants in R1s bed and S2 saw a total of 4 ants near the pillow and on at the foot of the bed. S2 also told S4 the credible witness tried to kill some of the ants that were on the bed. Based on the evidence gathered through interviews and records reviewed, the allegation is deemed substantiated at this time.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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 2
Control Number 29-AS-20210401162329
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: LORIE'S RCFE LLC #3
FACILITY NUMBER: 425850021
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
04/13/2021
Section Cited
CCR
87468.1
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87468.1 Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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The Administrator agreed to hold a personal rights training with all staff, and will submit proof of training to CCL.
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Based on interview, the facility did not provide R1 safe, healthful and comfortable accommodations, as ants were observed in R1’s bed, which poses a potential health, safety, and personal rights risk to residents in care.
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CCR
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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: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2