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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565850274
Report Date: 06/20/2025
Date Signed: 06/20/2025 03:39:59 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
06/13/2025 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20250613134719
FACILITY NAME:PETIT OASISFACILITY NUMBER:
565850274
ADMINISTRATOR:VINCECRUZ, SUSANFACILITY TYPE:
740
ADDRESS:2802 PETIT STREETTELEPHONE:
(805) 383-8894
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:6CENSUS: 4DATE:
06/20/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Susan VincecruzTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not ensure injections are administered by an appropriately skilled professional.
Staff are not documenting medications appropriately.
Administrator is not competent to meet the needs of residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint investigation visit for the above allegations. Upon arrival, the LPA met with Administrator, Susan Vincecruz and explained the reason for the visit. The Licensee Representative, Roberto Ramirez arrived shortly after. Entrance interview conducted.

During today's visit, the LPA conducted interviews with three staff and two residents between 10:07am and 11:45am, conducted a medication review at 10:30am, and conducted a file review and obtained copies of pertinent documents relevant to the investigation.

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

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
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 6
Control Number 29-AS-20250613134719
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: PETIT OASIS
FACILITY NUMBER: 565850274
VISIT DATE: 06/20/2025
NARRATIVE
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Report Continued from LIC 9099...

It was alleged that staff did not ensure injections are administered by an appropriately skilled professional. It was reported that Resident #1 (R1) is prescribed four units of Lantus every 12 hours, administered via an injection pen. However, R1 is unable to administer the injection independently. Interviews conducted with staff and R1 revealed that R1 is responsible for self-administering their medication. R1 stated that facility staff assist by bringing the injection pen to them but confirmed that they perform the injection themselves. During interview, R1 demonstrated to the LPA where and how they administer the injection. Additionally, a review of R1’s physician’s report dated 10/10/2024, lists R1’s primary diagnoses as mild cognitive impairment (MCI) and diabetes. Regarding the diabetes management, the report states that R1 is capable of managing their own treatment, medication, and equipment. Based on record review and interviews conducted, the Department has insufficient evidence to support the allegation or that a violation occurred. Therefore, allegation, “staff did not ensure injections are administered by an appropriately skilled professional” is deemed Unsubstantiated at this time.

It was also alleged that staff are not documenting medications appropriately. It was reported that the medication Lispro is supposed to be administered; however, it is not being documented as administered by facility staff. A review of R1’s medications, the Centrally Stored Medication and Destruction Record (CSMDR), and Medication Administration Records (MARs) revealed that Insulin Lispro, administered via injection pen, is being administered four (4) times per day. Staff interviews confirmed that R1’s blood glucose levels are being checked four times daily and that R1 self-administers their insulin injections. Staff also stated that the MARs are updated shortly after medications are distributed to all residents in the facility. Furthermore, at the time of the visit, the medications appeared to be properly documented on the CSMDR. Based on medication review and record review, the Department has insufficient evidence to support the allegation or that a violation occurred. Therefore, allegation “staff are not documenting medications appropriately” is deemed Unsubstantiated at this time.

Report Continued on LIC 9099C...

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

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20250613134719
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: PETIT OASIS
FACILITY NUMBER: 565850274
VISIT DATE: 06/20/2025
NARRATIVE
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Report Continued from LIC 9099C...

It was further alleged that Administrator is not competent to meet the needs of residents. It was reported that the Administrator is not properly trained to care for the residents. Interviews conducted with both facility staff and residents revealed that the Administrator is effectively meeting residents’ needs and providing assistance within the facility as needed. Residents stated that the Administrator checks on them daily and also assists with providing care and supervision throughout the day. Additionally, residents did not express any concerns regarding the Administrator's ability to meet their needs during interviews. Furthermore, record review of the Administrator’s personnel file revealed that the required annual training is up to date and that the Administrator’s certificate is valid through 04/06/2026. Based on the information obtained through record review and interviews, the Department has insufficient evidence to support the allegation or that a violation occurred. Therefore, allegation “Administrator is not competent to meet the needs of residents” is deemed Unsubstantiated at this time.

Exit interview conducted. Report was reviewed and copy provided.

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

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
06/13/2025 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20250613134719

FACILITY NAME:PETIT OASISFACILITY NUMBER:
565850274
ADMINISTRATOR:VINCECRUZ, SUSANFACILITY TYPE:
740
ADDRESS:2802 PETIT STREETTELEPHONE:
(805) 383-8894
CITY:CAMARILLOSTATE: CAZIP CODE:
93012
CAPACITY:6CENSUS: 4DATE:
06/20/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Susan VincecruzTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
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9
Staff did not ensure glucose checks are administered by an appropriately skilled professional.
Resident missed medication due to staff not ordering medication.
INVESTIGATION FINDINGS:
1
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3
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5
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7
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10
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Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint investigation visit for the above allegations. Upon arrival, the LPA met with Administrator, Susan Vincecruz and explained the reason for the visit. The Licensee Representative, Roberto Ramirez arrived shortly after. Entrance interview conducted.

During today's visit, the LPA conducted interviews with three staff and two residents between 10:07am and 11:45am, conducted a medication review at 10:30am, and conducted a file review and obtained copies of pertinent documents relevant to the investigation.

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

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20250613134719
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: PETIT OASIS
FACILITY NUMBER: 565850274
VISIT DATE: 06/20/2025
NARRATIVE
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Report Continued from LIC 9099...
It was alleged that staff did not ensure glucose checks are administered by an appropriately skilled professional. It was reported that R1 is supposed to have their blood glucose levels checked four times a day and at bedtime and the glucose levels are not being documented consistently. Interviews conducted with staff indicated that they assist R1 by bringing the necessary tools to perform glucose testing. Staff reported that R1 pricks their own finger and that they only provide the blood glucose meter for R1 to place the blood sample. Staff also stated that they document the glucose readings each time they are checked. However, during an interview, R1 confirmed that their blood glucose levels are checked at least four times a day but stated that facility staff perform the entire process by bringing the meter, pricking their finger, and documenting the results. At this time, R1 also noted that staff inform them of the glucose readings after each test. Furthermore, record review of R1’s physician’s report dated 10/10/2024, indicates under mental condition that R1 is not confused or disoriented. Based on the information obtained and reviewed, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff did not ensure glucose checks are administered by an appropriately skilled professional” is deemed Substantiated at this time.

It was also alleged that resident missed medication due to staff not ordering medication. It was reported that a medication list was emailed to the Administrator; however, the medication had not been ordered by the facility. A review of R1’s medications, Centrally Stored Medication and Destruction Record (CSMDR), and Medication Administration Records (MARs) revealed that R1 has not been receiving their medication as prescribed, as the medication ran out before a refill was received from the pharmacy. Interviews conducted with staff revealed that they notify the Administrator before medications run out; however, the refills do not always arrive on time from the pharmacy. As a result of not having the medication refills available, R1 has had missed doses. Based on record review and interviews conducted, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “resident missed medication due to staff not ordering medication” is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. There is a $250 civil penalty due to repeat violation of Section 87465(a)(4) as it has been cited previously within the last 12 months. Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

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

DATE: 06/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20250613134719
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: PETIT OASIS
FACILITY NUMBER: 565850274
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2025
Section Cited
CCR
87628(a)
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The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing… or has it administered by an appropriately skilled professional.
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The Licensee will review Regulation 87628 and submit a statement of understanding to CCL no later than POC due date.
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Based on interviews, the Licensee did not comply with the section cited above as facility staff are performing the glucose testing for R1, which poses an immediate health, safety, or personal rights risk to residents in care.
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Type A
06/23/2025
Section Cited
CCR
87465(a)
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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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The Licensee will review Regulation 87465 and submit a statement of understanding to CCL no later than POC due date.
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Based on record review and interviews, the Licensee did not comply with the section cited above as facility staff are not ensuring residents receive the refills on time resulting in missed dosages, which poses an immediate health, safety, or personal rights risk to residents in care.
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Civil Penalty assesed due to repeat violation.
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 Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6