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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801382
Report Date: 01/03/2022
Date Signed: 01/03/2022 11:39:03 AM

Unsubstantiated


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: 5DATE:
01/03/2022
UNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Wilfredo LadioTIME COMPLETED:
11:38 AM
ALLEGATION(S):
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Staff hit resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Guzman Chavez conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation and to conclude an investigation initiated on 10/21/2021. Upon arrival, the LPA met with Staff Wilfredo Ladio and explained the reason for the visit. Entrance interview conducted.

On 10/21/2021, LPA Guzman Chavez conducted an initial 10-day visit, at which time interviews were conducted with the Administrator, two (2) facility staff, four (4) residents, and a resident’s family member between 10:06 a.m. and 1:10 p.m.

It was alleged that staff hit resident. It was reported that Resident #1 (R1) was observed trying to open a dresser drawer underneath R1’s TV, and Staff #1 (S1) slapped R1 on the back of the leg. It was unknown whether R1 obtained any marks or bruising.
Continued on LIC 9099...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
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 2
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: 01/03/2022
NARRATIVE
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Continued from LIC 9099...

Interviews conducted with residents revealed that residents like living at the facility, and the staff treat them well. Residents also stated that facility staff have not inappropriately touched them. Interview with R1 revealed that R1 likes living at the facility, and that staff treats R1 ‘good.’ Interview with the Administrator revealed that S1 has been working at the facility for several years. Administrator stated that the facility does not tolerate any abuse by staff to residents, and residents communicate effectively with staff to be able to report any abuse. Interviews with staff revealed that they are aware of the consequences of abuse against residents. Staff stated that they take their ‘job seriously,’ and residents are well taken care of. Staff stated that all residents are treated nicely. Staff denied any knowledge of the residents being inappropriately touched. Interview with R1’s family member revealed that R1 has been doing better both physically and verbally since moving into the facility. R1’s family member also stated that R1 discloses everything to them, and they have no concerns with R1’s safety. Based on the interviews conducted, there is insufficient evidence to support the allegation. Therefore, the allegation "staff hit resident" is deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued. A copy of report provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2