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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609938
Report Date: 01/19/2024
Date Signed: 01/19/2024 03:17:51 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
08/08/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20230808151455
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: 6DATE:
01/19/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lidia MedinaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff failed to assist resident with medication.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs), Martha Arroyo and Valeria Conway conducted a subsequent visit to the facility to issue findings for the above allegation. The initial visit was conducted on 08/15/2023 by LPA M. Arroyo. During today's visit, LPAs met with Administrator, Lidia Medina and the reason for the visit was explained. Entrance interview.

During the initial visit on 08/15/2023, LPA Arroyo conducted interviews with the Administrator and two staff between 2:50 p.m. and 3:24 p.m., conducted a resident file review at 3:35 p.m., and obtained copies of pertinent documents relevant to the investigation. Telephonic interviews were also conducted with family members on 08/25/2023 at 2:12 p.m. and 08/28/2023 at 10:24 a.m.

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

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
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 5
Control Number 29-AS-20230808151455
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: 01/19/2024
NARRATIVE
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(Report Continued from LIC 9099..)

It was alleged that facility staff failed to assist resident with medication. It was reported that facility staff left at night and medication was inaccessible to residents until the morning. Interviews conducted with staff revealed that the facility had two (2) empty resident bedrooms and one (1) of those bedrooms was being used by the care staff at night. Staff stated the night medication that is scheduled before bedtime is usually given to the residents between 8pm – 9pm right before the resident’s usual time before falling asleep. Additionally, interviews conducted and records review revealed that all facility staff have completed the necessary training for medication including assisting residents with the administration of self- administered medication. Furthermore, staff are scheduled 24 hours each day and if needed, staff are available on premises at any time during the day or night. Based on the information obtained and reviewed, the Department does not have sufficient evidence to support the allegation of “facility staff failed to assist resident with medication”. Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/08/2023 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20230808151455

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: 6DATE:
01/19/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lidia MedinaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Facility staff are not providing adequate night supervision.
Licensee is not following the admission agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs), Martha Arroyo and Valeria Conway conducted a subsequent visit to the facility to issue findings for the above allegation. The initial visit was conducted on 08/15/2023 by LPA M. Arroyo. During today's visit, LPAs met with Administrator, Lidia Medina and the reason for the visit was explained. Entrance interview.

During the initial visit on 08/15/2023, LPA Arroyo conducted interviews with the Administrator and two staff between 2:50 p.m. and 3:24 p.m., conducted a resident file review at 3:35 p.m., and obtained copies of pertinent documents relevant to the investigation. Telephonic interviews were also conducted with family members on 08/25/2023 at 2:12 p.m. and 08/28/2023 at 10:24 a.m.

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

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20230808151455
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: 01/19/2024
NARRATIVE
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(Report Continued from LIC 9099...)
It was alleged that facility staff are not providing adequate night supervision. It was reported that facility staff are not available between 7pm to 7am and when a resident had an unwitnessed fall in the middle of the night, the facility staff did not find the resident until the following morning. Review of documents revealed that facility was licensed without a designated staff room; therefore, the facility was required to have 24-hour wake staff on premises. Additionally, facility staff schedule revealed that facility has one (1) staff member scheduled to stay awake all night and cover between 7pm to 7am. Interviews conducted with staff revealed that there is no designated staff room on premises; however, the staff is currently sleeping in a vacant resident bedroom. During the interviews, Staff #1 (S1) admitted to sleeping throughout the night and only waking up a couple times to use the restroom themselves. At this time, S1 stated they check on the residents. Although facility staff is on premises for 24 hours, staff was asleep for the majority of the nighttime rather than staying awake and supervising the residents. Furthermore, due to staff sleeping throughout the night, adequate night supervision was not being provided to residents. Based on the information obtained and reviewed, the Department has sufficient evidence to support the allegation of “facility staff are not providing adequate night supervision”. Therefore, this allegation is deemed Substantiated at this time. Although the allegation of “facility staff are not providing adequate night supervision” was Substantiated, it has already been cited on a separate CC#29-AS-20230728084857 today 01/19/2024.

It was also alleged that licensee is not following the admissions agreement. It was reported that the facility recently updated the admissions agreement with a different rate and back dated the admissions agreement. Information obtained during the course of the investigation revealed that Resident #1 (R1) was admitted to the facility on 05/22/2023. Per R1’s admissions agreement dated 05/23/2023, it states on page 15 section D following a resident’s death that “a refund of any fees paid in advance…shall be issued to the entity contractually responsible for the fees…within 15 days after the personal property is removed”. However, on R1’s admissions agreement on page 5 under Rate for Basic Services, extra verbiage was added after the admissions agreement had been originally signed by R1’s Power of Attorney (POA) on 05/23/2023 that stated “6800 for 2 months, if R1 passed within this period there is no refund” which had a date of 06/12/2023. Furthermore, similar verbiage was added on page 6 that stated “Basic Rate 6800 for the first 2 months. No refund back”. Based on the information obtained and reviewed, the Department has sufficient evidence to support the allegation of “licensee is not following the admissions agreement”. Therefore, this allegation is deemed Substantiated at this time.

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: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20230808151455
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: 01/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/22/2024
Section Cited
CCR
87507(f)
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87507 (f) Admissions Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement…
This requirement was not met as evidenced by:
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The Licensee has agreed to review Regulation 87507 on Admissions Agreements and submit a statement of understanding to CCL no later than 01/22/2024.
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Based on record review, the licensee did not comply with the section cited above as licensee manually added verbiage after the admissions agreement was signed by R1’s POA which contradicted with the original terms, which poses a potential personal rights violation 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: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5