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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802133
Report Date: 09/13/2023
Date Signed: 10/02/2023 12:38:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
09/13/2023 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20230913081312
FACILITY NAME:ROSE GARDEN MANOR IVFACILITY NUMBER:
565802133
ADMINISTRATOR:SORATORIO, AMALIAFACILITY TYPE:
740
ADDRESS:745 BERKSHIRE PLACETELEPHONE:
(805) 246-5148
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 6DATE:
09/13/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Amalia SoratorioTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Uncleared staff working at the facility.
Facility staff are untrained.
INVESTIGATION FINDINGS:
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On 10/02/2023, LPA Urena conducted a visit to amend this report. The LPA met with the administrator and explained the reason for the visit. This is an amended report to reflect the correct citation for the violation and to assess civil penalties for the violation.
Licensing Program Analyst (LPA) Sandra Urena conducted an unannounced 10-day visit to investigate the allegations listed above. The LPA met with administrator Amalia Soratorio and explained the reason for the visit.
At 1:30 p.m. the LPA requested and reviewed records pertaining to the allegations. The LPA interviewed staff at 1:55 p.m. and interviewed the administrator at 2:20 p.m.

Continues on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
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 3
Control Number 29-AS-20230913081312
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROSE GARDEN MANOR IV
FACILITY NUMBER: 565802133
VISIT DATE: 09/13/2023
NARRATIVE
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Uncleared staff working at the facility.
On the allegation that uncleared staff are working at the facility, it is the concern of the reporting party that staff without background clearance are working at the facility. To investigate the allegation, the LPA requested staff’s records for the staff reflected on the LIC500 (Personnel Roster). The LPA reviewed records and the reviewed revealed that one staff member was not background cleared. The interview with staff revealed that they had started working recently at the facility and could not provide proof of receiving background clearance. The interview with the administrator revealed that one staff, was hired recently and that they had submitted documentation to the CCLD Regional Office. However, the administrator could not provide proof of the staff being background cleared.

Based on the information obtained through interviews and record review, there is sufficient evidence to support the allegation that staff without background clearance are working at the facility. Therefore, the allegation is deemed Substantiated at this time.

Facility staff are untrained.
On the allegation that facility staff are untrained, it is the reporting party’s concern that staff are working with residents and have not been properly trained. To investigate the allegation, the LPA conducted staff record review, and interviewed staff and the administrator. The record review revealed that one (1) out of five(5) staff did not receive training. The Administrator interview revealed that the staff was being oriented and was receiving training on site. The staff’s interview revealed that they received training in Direct Support Professional training in 04/18/2017 and 05/18/2018, but not current training by the facility.

Based on the information obtained through interviews, and record review, there is sufficient evidence to support the allegation that facility staff are untrained. Therefore, the allegation is deemed Substantiated at this time.
Pursuant to Title 22 of the CA Code of Regulations (CCR), the following deficiencies were cited (refer to LIC 809-D)

Citations were issued. Exit interview conducted. A copy of the report and Appeal Rights were issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20230913081312
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROSE GARDEN MANOR IV
FACILITY NUMBER: 565802133
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2023
Section Cited
CCR
87355(e)(1)
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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department or ...This requirement is not met as evidenced by:
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 The Administrator has agreed to do the following: Obtain verification from DOJ Background Check Bureau to show that S1 is cleared prior to working at the facility. S1 will not work at the facility until they are cleared.
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Based on observation, the licensee did not comply with the section cited above as one (1) out of six (6) staff did not have a criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
10/27/2023
Section Cited
CCR
87411(d)(3)
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 Personnel Requirements – General (d) All personnel shall be given on the job training.…(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by:
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The Administrator has agreed to do the following: To provide 40 hours of initial training (per regulations) to staff prior to starting to work directly with residents
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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: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
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