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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609938
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:37:00 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
09/06/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20230906105718
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:
09/08/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lidia MedinaTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility failed to issue a refund.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint visit to the facility for the above allegation. Upon arrival, LPA met with the Administrator and the reason for the visit was explained. Entrance interview conducted.

During today’s visit, the LPA interviewed the Administrator at 2:50 p.m., conducted a file review at 3:00 p.m., and obtained copies of pertinent documents.

Regarding the allegation: Facility failed to issue a refund. It was alleged that facility failed to issue a refund to Resident #1’s (R1’s) family. Review of documents revealed R1 was no longer living in the facility by 08/12/2023. Additionally, interviews conducted revealed R1’s family had also removed all of R1’s personal belongings from the facility by 08/12/2023.

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

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
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-20230906105718
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: 09/08/2023
NARRATIVE
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(Report Continued from LIC 9099...)

Furthermore, information obtained and reviewed revealed the facility has issued R1’s family a refund for the pro-rated amount for the month of August on 08/29/2023 which was cleared on 09/05/2023. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “facility failed to issue a refund”. Therefore, this allegation is being deemed Unsubstantiated at this time.

Exit interview conducted. No citations issued at this time. A copy of the report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2