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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609938
Report Date: 03/29/2023
Date Signed: 03/29/2023 02:11:25 PM

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
11/16/2022 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20221116082417
FACILITY NAME:RESIDENTIAL FIRST CARE, LLCFACILITY NUMBER:
567609938
ADMINISTRATOR:MEDINA, LIDIAFACILITY TYPE:
740
ADDRESS:6109 VERA STTELEPHONE:
(805) 842-1679
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 4DATE:
03/29/2023
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Lida MedinaTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff is not providing Ombudsman Representative with resident's records upon request.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to this facility today regarding above allegation. Upon arrival LPA met with staff and Administrator was contacted. Reason for visit was explained and allegation finding was discussed with Administrator by telephone.
Following is a summary of the investigation:
On 11/22/2022, a complaint visit was initiated and between 2:30pm-2:45pm, Resident (R1) records was reviewed and copies obtained. Between 2:45pm-3:15pm, LPA conducted interview with R1.
On 01/30/2023, potential witness who is a reliable source was interviewed approximately 1pm. Information was provided that the Administrator did not provide R1's records when requested to assist R1 with a specific request. Administrator reported that R1's file was eventually provided however she was not certain about whether or not she can provide copy of the power of attorney records.
Based on the information gathered, the allegation is deemed Substantiated at this time.
Pursuant to Title 22, California Code of Regulations, the deficiency will be cited on 9099-D.
Exit interview conducted, deficiency cited, copy of this report and appeal rights provide.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
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 2
Control Number 29-AS-20221116082417
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: RESIDENTIAL FIRST CARE, LLC
FACILITY NUMBER: 567609938
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/30/2023
Section Cited
CCR
87405(d)(2)
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Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)..all requirements for an administrator shall apply.
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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Administrator eventually provided the records to the Long Term Care Ombudsman (LTCO) representative and resident. Administrator agreed to submit a self-certification letter of understanding that all other agency requirements need to be followed. Submit letter by 03/30/2023.
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This requirement is not met as evidence by:
Based on interviews conducted Administrator did not comply with the request of the LTCO representative who requested to review R1's file to further assist R1 in a specific matter.
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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: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC9099 (FAS) - (06/04)
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