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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565802427
Report Date: 05/05/2021
Date Signed: 05/05/2021 11:59:06 AM

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
04/27/2021 and conducted by Evaluator Kelly Dulek
PUBLIC
COMPLAINT CONTROL NUMBER: 29-AS-20210427084005
FACILITY NAME:DELPHINIUM MANORFACILITY NUMBER:
565802427
ADMINISTRATOR:GONZALES, HERMIFACILITY TYPE:
740
ADDRESS:691 DELPHINIUM PLTELEPHONE:
(805) 919-9770
CITY:OXNARDSTATE: CAZIP CODE:
93036
CAPACITY:6CENSUS: 6DATE:
05/05/2021
UNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Hermi GonzalesTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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Cement sidewalk on facility property creates a trip and/or fall hazard to residents
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kelly Dulek and Angel Ascencio initiated a complaint investigation for the allegations listed above at 9:19 AM. LPAs Dulek and Ascencio met with facility Administrator Hermi Gonzales and discussed the reason for today's visit. Entrance interview conducted.

LPAs interviewed Administrator Hermi Gonzales at 9:25AM and conducted a physical plant tour at 9:35AM. LPAs photographed areas pertinent to the investigation during the tour. Administrator discussed the walkway and is aware there is a drop off on the edge of the walkway. LPAs observed trash cans blocking the side gate from fully opening and therefore obstructing the walkway, creating a narrow path. Additionally, there is a hedge that is impeding on the walkway and a shopping cart stored in the walkway. LPAs confirmed the side gate and walkway is utilized as an emergency exit and all current residents are non-ambulatory. Location of the trash cans, hedge, and shopping cart causes a narrow pathway close to the sidewalk drop off/uneven surface, creating a fall hazard to residents in care. Therefore, the allegation that "cement sidewalk on facility
REPORT CONTINUED ON LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
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 3
Control Number 29-AS-20210427084005
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: DELPHINIUM MANOR
FACILITY NUMBER: 565802427
VISIT DATE: 05/05/2021
NARRATIVE
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property creates a trip and/or fall hazard to residents" is SUBSTANTIATED at this time.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. A copy of the report and appeal rights were provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20210427084005
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: DELPHINIUM MANOR
FACILITY NUMBER: 565802427
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors
This requirement is not met as evidenced by:
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Administrator agreed to build an alternate storage area for the trash cans, trim the hedge and remove the shopping cart from the walkway. Administrator will submit photographs of the new storage area and clear walkway to CCLD by 5/19/2021.
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Based on observation, the walkway is partially obstructed, causing a narrow pathway with an uneven surface, which poses a potential safety risk to residents in care.
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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: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3