567609938-8-4-2023-29-AS-DPEA-CUYTB5-20230823143435

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 567609938
Report Date: 08/04/2023
Date Signed: 08/04/2023 03:56:29 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
07/31/2023 and conducted by Evaluator Martha Arroyo

COMPLAINT CONTROL NUMBER: 29-AS-20230731091654

FACILITY NAME:	RESIDENTIAL FIRST CARE, LLC		FACILITY NUMBER:	567609938
ADMINISTRATOR:	MEDINA, LIDIA		FACILITY TYPE:	740
ADDRESS:	6109 VERA ST		TELEPHONE:	(805) 842-1679
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 4	DATE:	08/04/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Lidia Medina		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff does not ensure facility has adequate food supply.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint visit for the above allegation. Upon arrival, the LPA met with the Administrator and the reason for the visit was explained. Entrance interview conducted.

During today's visit, the LPA conducted a tour of the facility’s kitchen, pantry, and garage at 1:50 p.m. and conducted an interview with the Administrator at 2:00 p.m.

It was alleged that staff do not ensure facility has adequate food supply. It was reported that insufficient amounts of food were observed in the facility and rotten fruit was also observed in the fruit bowl. While conducting the walkthrough, the LPA observed the facility’s food supply in the kitchen, pantry, and garage.

(Report Continued on LIC 9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20230731091654

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
	VISIT DATE: 08/04/2023

NARRATIVE

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(Report Continued from LIC 9099...)

The LPA observed the sufficient two (2) days perishables and seven (7) days non-perishable foods which included food from all groups such as meats, dairy, eggs, breads, and fresh fruits that included oranges, bananas, and watermelon. Interviews conducted with the Administrator revealed grocery shopping is done once a week for non-perishables and twice a week for perishables such as fruits and vegetables. Based on LPA observations, the Department does not have sufficient evidence to support the allegation of “staff do not ensure facility has adequate food supply”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued. A copy of the report was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC9099 (FAS) - (06/04)

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