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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610007
Report Date: 03/22/2024
Date Signed: 03/22/2024 04:11:09 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
02/29/2024 and conducted by Evaluator Martha Arroyo
COMPLAINT CONTROL NUMBER: 29-AS-20240229150859
FACILITY NAME:VARENITA OF SIMI VALLEYFACILITY NUMBER:
567610007
ADMINISTRATOR:VEIS, MARGIEFACILITY TYPE:
740
ADDRESS:3921 COCHRAN STREETTELEPHONE:
(805) 327-1100
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:110CENSUS: 100DATE:
03/22/2024
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Margie VeisTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff increased resident fees without providing new additional services.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of the visit is to deliver findings for the above allegation. The initial visit was conducted on 03/04/2024 by LPA M. Arroyo. On today's visit, LPA Arroyo met with Executive Director (ED), Margie Veis. Entrance interview.

During the initial visit on 03/04/2024, LPA Arroyo conducted an interview with the ED at 1:50 p.m., conducted a file review at 2:30 p.m., and obtained copies of pertinent documents relevant to the investigation.

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

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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 3
Control Number 29-AS-20240229150859
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: VARENITA OF SIMI VALLEY
FACILITY NUMBER: 567610007
VISIT DATE: 03/22/2024
NARRATIVE
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Continued from LIC 9099C...

It was alleged that staff increased resident fees without providing new additional services. It was reported that no additional services have been added to justify the increase in resident fee. Records review revealed that residents who were assed prior to being admitted to the facility as independent were not charged any additional fees as they required no additional services already being provided in the basic monthly fee. Additionally, residents did not require assistance with any activities of daily living (ADL’s) including medication management. A review of random resident admission agreements revealed that five (5) out of five (5) admission agreements did not have an updated admissions agreement disclosing the rate change. Although the facility submitted a change of Assessment Tool, Structure of Level of Care Levels and Resident Agreements on 03/09/2023, residents who are scheduled to have an increase in resident fees by April 2024 have yet to sign an Addendum to current admissions agreement or an updated admissions agreement that reflects new information pertaining to the Structure of Level of Care Levels. Furthermore, residents received a letter from the facility corroborating the statement that no additional services will be provided to residents following the fee increase in April 2024. Based on the information obtained and reviewed, the allegation of, “staff increased resident fees without providing new additional services” is being deemed Substantiated at this time.

The following deficiencies were observed (See LIC 9099-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in 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: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240229150859
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: VARENITA OF SIMI VALLEY
FACILITY NUMBER: 567610007
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/27/2024
Section Cited
HSC
1569.655
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(a)If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount ...
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to Health & Safety Code 1569.655(a); The written letter must be sent to the LPA by the POC due date.
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of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident....

This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above as the resident’s admissions agreement are not updated or have an addendum on file that reflects residents new structure of level of care levels as stated on plan of operation, which poses a potential personal rights risk to persons 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: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
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