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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801382
Report Date: 03/21/2024
Date Signed: 03/21/2024 06:56:08 PM

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
02/23/2024 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20240223090557
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: 4DATE:
03/21/2024
UNANNOUNCEDTIME BEGAN:
06:15 PM
MET WITH:Elisa TalboTIME COMPLETED:
07:00 PM
ALLEGATION(S):
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Staff confined residents to their rooms.
Staff did not provide a safe and comfortable environment for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent visit to the facility to issue findings for the above allegations. The initial visit was conducted on 02/29/2024 by LPA M. Arroyo. During today's visit, LPA met with staff, Elisa Talbo. The staff called the Administrator, Annabelle Ramos at 6:25 p.m. and LPA shared findings telephonically. Entrance interview.

During the initial visit on 02/29/2024, the LPA conducted a tour of the facility to ensure there were no immediate health and safety concerns at 9:10 a.m., conducted interviews with the Administrator, one staff member, and three residents between 9:30 a.m. and 10:45 a.m., and obtained copies of pertinent documents relevant to the investigation. On 03/01/2024, LPA Arroyo conducted a telephonic interview with Simi Valley Officer (SVO) at 9:46 a.m. Police Report was also obtained and reviewed.

Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
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-20240223090557
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: 03/21/2024
NARRATIVE
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Continued from LIC 9099C...

It was alleged that staff confined residents to their rooms and staff did not provide a safe and comfortable environment for residents. It was reported that facility staff is using rope and a screwdriver as a method to prevent residents from exiting their bedrooms and is a method of restraining residents within their bedrooms. During the facility walkthrough on 02/29/2024, the LPA observed two (2) residents in their beds, one (1) resident sitting in their room browsing through a magazine, and one (1) resident watching television in the living room. LPA observed all door and doorknobs in the facility, and rope was nowhere in sight at the time of the visit. Additionally, holes on the walls were observed to be filled in and closed upon LPA inspection. Interview conducted with law enforcement revealed that two (2) officers had received a call to conduct a welfare check at the facility. Officer stated that upon arrival, facility staff opened the front door and allowed them to go inside without hesitation. Residents were observed inside their rooms on their beds and others doing activities. Additionally, officers went to every single room and did not observe any screwdrivers in sight or rope hanging anywhere or visible. Furthermore, per Police Report it states inspection demonstrated a commitment to maintaining a safe and nurturing environment for its residence and no violations of concerns were identified during the search. Interviews conducted with staff revealed that the holes have been present at the facility prior to them working at the facility. Additionally, staff added that all room doors have door locks for residents to use if they want privacy at any time. Interviews conducted with residents revealed that staff encourage the residents to go outside; however, they choose to stay inside. Additionally, residents stated that family members often come to the facility and visit. Furthermore, residents stated they are comfortable living at the facility and reported feeling safe. Although the allegations may have happened or are valid, there is insufficient evidence to prove the alleged violations occurred, therefore these allegations are deemed Unsubstantiated at this time.

No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2