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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610022
Report Date: 10/24/2024
Date Signed: 10/24/2024 02:36:32 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
08/08/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240808150455
FACILITY NAME:APPLETON HOMESFACILITY NUMBER:
567610022
ADMINISTRATOR:OLIVAS, MYLINEFACILITY TYPE:
740
ADDRESS:1149 APPLETON RDTELEPHONE:
(747) 237-0417
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 4DATE:
10/24/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Myline OlivasTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff leaves resident in soiled clothing for an extended amount of time.
Staff does not provide adequate food portions to residents.
Staff are forcing a resident to sleep early.
Staff did not administer resident medication as prescribed.
Staff did not meet resident's showering needs.
Staff not providing residents with laundry service.
Staff did not ensure that a resident's was provided their oxygen.
Staff confines resident to room.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Balisi conducted a subsequent complaint visit to investigate the allegations listed above. During today’s visit, LPA met with staff and explained the reason for the visit. Administrator Myline Olivas arrived shortly after.
On 08/15/2024, the initial complaint visit was conducted by LPA between approximately 09:30 a.m. - 1:45 p.m. During the visit, LPA’s conducted physical plant, interviewed staff, residents, as well as, reviewed and obtained copies of pertinent documentation relevant to the investigation. At approx. 10:40 a.m. LPA conducted physical plant, interviewed staff , interviewed families / responsible parties conducted medication audit and reviewed and obtained additional pertinent documentation relevant to the investigation.

It was reported that "Staff leave residents in soiled clothing for an extended amount of time”, as it was alleged Resident #1 (R1) and other residents do not get their clothes changed in a timely manner. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated they have never observed any residents in soiled clothing and are always dressed in a timely manner.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 6
Control Number 29-AS-20240808150455
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: APPLETON HOMES
FACILITY NUMBER: 567610022
VISIT DATE: 10/24/2024
NARRATIVE
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Continued from 9099
These (3) residents also did not express any immediate or potential concerns for any residents being left in soiled clothing for an extended amount of time. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed that residents are changed every morning. If they observe any piece of clothing to be soiled, they change it right away. Each staff interviewed have never observed any resident left in soiled clothing for an extended amount of time. LPA's interview with five (5) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for residents being left in soiled clothing for an extended amount of time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff leaves resident in soiled clothing for an extended amount of time” is deemed Unsubstantiated at this time.

It was reported that "Staff does not provide adequate food portions to residents" as it was alleged that residents were provided small portions of food, and they were not able to get seconds. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated most of the time there is too much food served. These (3) residents also did not express any immediate or potential concerns for asking for a second serving of food or the food portions. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed they have never observed any staff deny a resident a second serving of food or get served an inadequate portion of food. LPA's interview with five (5) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for the portion of food served to the residents or residents being denied a second serving of food. During physical plants, LPA observed food served to be sufficient in portions as well as observed at least (2) residents who did not finish their food due to the amount of food served. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff does not provide adequate food portions to residents” is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20240808150455
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: APPLETON HOMES
FACILITY NUMBER: 567610022
VISIT DATE: 10/24/2024
NARRATIVE
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It was reported that "Staff are forcing a resident to sleep early", as it was alleged that staff would force residents to sleep at 6pm. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated that they have never been forced to sleep at a certain time and each have never observed staff force other residents to sleep at a specific time. Additionally, residents interviewed were asked about their daily routine and they mentioned that residents start early every day as they all wake up early. According to residents, breakfast is usually ready before 7:00am, lunch is around 11:00am, and dinner is before 5:00pm. Also, there is no set bedtime for residents. Interviews with residents also revealed, that some residents have dinner then want to settle down in their room. LPA's interview with five (5) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for the time the residents go to sleep. In addition, they stated if the residents do not complain about their bedtime, they have no problem with it either. Interviews with facility staff revealed residents wake up early in the morning every day. When asked about resident’s daily routine, staff said residents are usually awake while they do their morning routine checks at approx. 06:30 a.m. During the morning routine check, staff take residents out to the living room to have breakfast and start their day. When asked about bedtimes, staff interviews revealed, there is no bedtime, residents ask to go to their rooms shortly after having dinner stating they are tired and would like to go to relax. Furthermore, interview with the Administrator revealed, staff accommodate residents by taking them to their rooms early in the day per resident’s request. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff are forcing a resident to sleep early” is deemed Unsubstantiated at this time.

It was reported that "Staff did not administer resident medications as prescribed" as it was alleged that staff are not providing residents with the evening medications. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated they do not recall ever missing a dosage of medication. These (3) residents also did not express any immediate or potential concerns for missing a dosage of medications.Two (2) out of the (5) residents were not able to communicate effectively. LPA's medication review conducted on 10/24/2024 revealed all medications were administered as prescribed at this time. Evening Medications for Resident #2 (R2), Resident #4 (R4) and Resident #5 (R5) were typically administered between 7:00 p.m. - 8:00 p.m.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 29-AS-20240808150455
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: APPLETON HOMES
FACILITY NUMBER: 567610022
VISIT DATE: 10/24/2024
NARRATIVE
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Continued from 9099-C
LPA's interview with four (4) staff revealed that residents typically receive their evening medication shortly after dinner between approximately 7:00 p.m - 8:00 p.m.. Each staff interviewed also stated they have never observed any resident miss a dosage of medication in the evening. LPA's interview with five (5) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for any resident missing a dosage of medication. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not administer resident medications as prescribed” is deemed Unsubstantiated at this time.

It was reported that "Staff did not meet resident's showering needs" as it was alleged that staff did not shower residents in a timely manner. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated that residents shower every day. These (3) residents also did not express any immediate or potential concerns for not being showered in a timely manner. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed that residents are typically showered every morning. If they refuse, they attempt to ask them to shower at least (3) more times. Each staff interviewed also stated they have never observed any resident not showered in a timely manner. LPA's interview with five (5) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for residents not being showered in a timely manner. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not meet resident's showering needs” is deemed Unsubstantiated at this time.

It was reported that "Staff not providing residents with laundry service", as it was alleged that staff are not doing resident's laundry in a timely manner. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated that laundry is completed every day. Staff gather dirty clothes in the morning and the cleaned clothes return to their room folded by the late afternoon. These (3) residents also did not express any immediate or potential concerns for laundry not being completed in a timely manner. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed that resident’s laundry is completed every day.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20240808150455
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: APPLETON HOMES
FACILITY NUMBER: 567610022
VISIT DATE: 10/24/2024
NARRATIVE
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Continued from 9099-C
Staff gather the dirty clothes in the morning. The laundry is usually completed by the afternoon where it is folded and returned to the resident. Each staff interviewed also stated they have never observed any resident’s laundry not being completed in a timely manner. During visit on 08/21 at approx. 01:55 p.m. LPA observed staff remove various garments of clothing then proceeded to fold clothing to return back to resident’s room. LPA's interview with five (5) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for residents’ laundry not being completed in a timely manner. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff not providing residents with laundry service” is deemed Unsubstantiated at this time.

It was reported that "Staff did not ensure that a resident was provided their oxygen" as it was alleged that R2 was not promptly provided their oxygen. Interviews conducted and records review revealed that upon admission on 05/03/2024, R2 did not have an order for oxygen. On 05/04/2024, R2 was assessed by Home Health services which prescribed Oxygen at 2 L/min via nasal cannula continuously to start on 07/03/2024 Records review revealed R2 has been administered oxygen since start date. LPA's interview with R2 revealed they do not recall ever being without their oxygen at this time. LPA's interview with four (4) staff revealed that R2 is administered their oxygen as prescribed. Each staff interviewed also stated they had no concerns for R2 being without their oxygen at this time. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff did not ensure that a resident was provided their oxygen” is deemed Unsubstantiated at this time.

It was reported that "Staff confines resident to room", as it was alleged that Resident #3 (R3) is not allowed outside of their room. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed are free to walk around the home and have never observed any resident not allowed to exit their room. These (3) residents also did not express any immediate or potential concerns for staff confining any resident to their room.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20240808150455
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: APPLETON HOMES
FACILITY NUMBER: 567610022
VISIT DATE: 10/24/2024
NARRATIVE
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Continued from 9099-C

Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed that residents are free to walk around the home unless they don't feel like leaving their room. LPA's interview with three (3) responsible parties / families of residents in care revealed they did not express any potential or immediate concerns for any resident being confined to their room. During physical plants on 08/15 and 08/21, LPA observed R3 out of their room and interacting with staff and residents. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation, “Staff confines resident to room” is deemed Unsubstantiated at this time.

Exit interview conducted and copy of report issued
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6