<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801382
Report Date: 10/21/2021
Date Signed: 10/21/2021 03:42:27 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
10/15/2021 and conducted by Evaluator Martha Guzman-Chavez
COMPLAINT CONTROL NUMBER: 29-AS-20211015120438
FACILITY NAME:ANNA'S HOME FOR THE ELDERLYFACILITY NUMBER:
565801382
ADMINISTRATOR:ANNABELLE RAMOSFACILITY TYPE:
740
ADDRESS:3325 ELMORE STREETTELEPHONE:
(805) 285-0385
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 6DATE:
10/21/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Annabelle RamosTIME COMPLETED:
03:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident has access to dangerous item.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced initial 10 day visit for the above allegations. LPA was scanned and greeted by staff, Elisa Talbo. At 9:47am, Administrator Annabelle Ramos arrived at the facility and was explained the reason for the visit. Entrance interview conducted.

During today's inspection, LPA conducted a physical plant tour with Administrator Annabelle Ramos at 9:51am.

It was alleged that on 10/15/2021, resident has access to dangerous item. It was reported that there is a pin that goes into the door at the bottom when it’s locked, but it’s accessible so that R1 can pull it out and could hurt themselves or others.

(Continued on LIC 9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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 4
Control Number 29-AS-20211015120438
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: ANNA'S HOME FOR THE ELDERLY
FACILITY NUMBER: 565801382
VISIT DATE: 10/21/2021
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
(Continued from LIC 9099...)

During the plant visit, at 12:48pm, LPA observed a long nail to be used on the front door to keep residents from leaving the facility. Interview with the Administrator revealed that R1 wanders off and tries to leave the facility. Furthermore, interviews with the staff revealed that R1 becomes agitated at times and removes the auditory alarm from the door and can open the front door and walk out. Based on interviews and the information obtained, it has been determined that the allegation, "Resident has access to dangerous item" is deemed Substantiated at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):



Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 29-AS-20211015120438
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: ANNA'S HOME FOR THE ELDERLY
FACILITY NUMBER: 565801382
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2021
Section Cited
CCR
87705(I)(6)
1
2
3
4
5
6
7
87705 Care of Persons with Dementia (I)(6)The following initial and continuing requirements shall be met for the licensee to lock exterior doors...shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Staff removed nail during facility visit. Staff stated that they will provide documentation of scheduled staff training regarding regulation 87705 to CCL and pictures of door with nail hole closed/sealed by 10/22/21.
8
9
10
11
12
13
14
Based on LPA observation and interviews, the licensee did not comply with the section cited above as there is a nail being used to keep front door locked from inside and accessible to residents which poses an immediate safety risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4