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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610022
Report Date: 01/29/2025
Date Signed: 01/29/2025 01:54:15 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
08/16/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240816153518
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: 5DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Myline OlivasTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not provide resident with privacy
Staff did not provide a comfortable environment for residents
Staff left resident unattended for extended periods
Staff did not treat resident with dignity and respect
Staff did not ensure that the resident’s broken recliner was replaced with a new one
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 staff and explained the reason for the visit. Administrator Myline Olivas arrived shortly after.

On 08/21/2024, the initial complaint visit was conducted by LPA between approximately 12:20 a.m. - 3:30 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. On 10/24/2024, LPA conducted a subsequent visit from approximately 10:30 a.m. – 3:00 p.m. and conducted physical plant, interviewed staff , families / responsible parties of residents in care and reviewed and obtained copies of additional pertinent documentation relevant to the investigation. Today LPA conducted interviews with staff as well as family / responsible parties.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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 8
Control Number 29-AS-20240816153518
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: 01/29/2025
NARRATIVE
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It was reported that "Staff did not provide resident with privacy" as it was alleged that Resident #1 (R1) was being changed in the open. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated that all resident are always given privacy when staff assist them with changing their clothes. These (3) residents also stated they have never observed any resident being changed while they were sitting on the couch watching television. In addition the (3) residents interviewed did not express any potential or immediate concerns for not being afforded privacy to change while in care. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed that typically residents are changed in their room in the morning when they wake up and in the evening before they go to bed. If they need to change the resident they would bring them to their room. Each staff interviewed have never observed any staff change a resident in any of the common areas at this time. LPA's interview with five (5) responsible parties / families of residents in care revealed that four (4) out of the (5) parties stated they have never observed a resident changed in the common areas and each they did not express any potential or immediate concerns for residents not being afforded their privacy at this time. One (1) out of the (5) responsible parties / families interviewed stated they have heard of a resident being changed in the common area, but they did not observe it first hand. 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 provide resident with privacy” is deemed Unsubstantiated at this time.

It was reported that "Staff did not provide a comfortable environment for residents" as it was alleged that while residents were having lunch Resident #2 (R2) was allowed to use their bedside commode in the living room in close proximity to other residents in care. LPA's interviews conducted with residents revealed that three (3) out of the five (5) residents interviewed stated that they have never observed R2 use a commode in the living room. Two (2) residents stated that staff assist them to their room or to the restroom while one (1) resident stated they use the restroom in the hallway bathroom without full assistance from staff. 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 assist R2 with using the commode in the restroom. Staff also stated that residents are brought to their room or restroom when they need to use the toilet. LPA's interview with five (5) responsible parties / families of residents in care revealed that four (4) out of the (5) parties stated they have never observed any resident use a bedside commode in the common area.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20240816153518
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: 01/29/2025
NARRATIVE
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One (1) out of the (5) responsible parties / families interviewed stated they have heard of a resident using a bedside commode in the living room , but they did not observe it firsthand. 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 provide a comfortable environment" for residents” is deemed Unsubstantiated at this time.
It was reported that "Staff left resident unattended for extended periods" as it was alleged that R2 was left in bed for (4) hours on 08/11. Interviews conducted and records review revealed that three (3) out of the five (5) residents interviewed stated that they have never observed R2 left in bed for a prolonged period of time. These (3) residents also stated that R2 is frequently in the living room watching television with other residents. 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 R2 left in the bed for a prolonged period of time, however if R2 wanted to lay in bed and not join the other residents in the common area they would let R2 do that as well. In addition, staff stated R2 LPA's interview with five (5) responsible parties / families of residents in care revealed that four (4) out of the (5) parties stated they have never observed any resident left in bed for a prolonged period of time. One (1) out of the (5) responsible parties / families interviewed stated they have heard of a resident being left in the bed for an extended period of time, but they did not observe it firsthand. During LPA's physical plants on 08/15/2021 and 08/21/2024, LPA observed R2 outside of bedroom watching television, eating lunch , having snacks and having conversations with staff. 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 left resident unattended for extended periods” is deemed Unsubstantiated at this time.

It was reported that "Staff did not treat resident with dignity and respect" as it was alleged that staff say insensitive and unprofessional comments out loud about residents in care. Interviews conducted revealed that three (3) out of the five (5) residents interviewed stated that they have never observed any staff say anything unprofessional or inappropriate about residents in care. These (3) residents also stated that they have no immediate or potential concerns for staff to say anything unprofessional or inappropriate about any residents. 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 say anything unprofessional or inappropriate about residents in care.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20240816153518
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: 01/29/2025
NARRATIVE
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.In addition, staff stated they always have conversations and joke around with residents , but no one ever says anything inappropriate towards other residents. LPA's interview with five (5) responsible parties / families of residents in care revealed that four (4) out of the (5) parties stated they have never observed any staff say anything unprofessional or inappropriate about residents in care. One (1) out of the (5) responsible parties / families interviewed stated they have heard of staff speaking unprofessional and inappropriate about residents in care, but they did not observe it firsthand. During LPA's physical plants on 08/15/2021 and 08/21/2024, LPA observed staff having pleasant conversations and joking around with residents in care. 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 treat resident with dignity and respect” is deemed Unsubstantiated at this time.

It was reported that "Staff did not ensure that the resident's broken recliner was replaced with a new one", as it was alleged Resident #3 (R3) had a broken recliner, which staff had to use additional objects to prop up feet. Interviews conducted with the Administrator revealed that R3 has never been in a recliner that was in disrepair. LPA observed recliner that R3 was using and it appeared to be in operable condition. Interviews conducted with five (5) residents revealed that three (3) out of the five (5) residents stated that they have never observed any recliner to not function properly or appear to be in disrepair. These (3) staff also stated that if they did observe anything broken that staff would either fix it or replace it right away. Two (2) out of the (5) residents were not able to communicate effectively. LPA's interview with four (4) staff revealed that three (3) out of the (4) interviewed have never observed any broken piece of furniture. (1) staff stated that recently they had a broken shower head and it was replaced the next day. LPA's interview with five (5) responsible parties / families of residents in care revealed that all four (4) out of the (5) parties stated they have never observed any broken piece of furniture in use by residents in care. One (1) out of the (5) responsible parties / families interviewed stated when they initially arrived to the home they observed multiple pieces of furniture outside of the home on the sidewalk, but they have never observed any broken piece of furniture in use by residents in care inside of the home. During LPA's physical plants on 08/15/2021 and 08/21/2024, LPA did not observe any broken piece of furniture. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. (Continued on 9099-C)
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20240816153518
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: 01/29/2025
NARRATIVE
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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 the resident's broken recliner was replaced with a new one” 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: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
08/16/2024 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20240816153518

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: 5DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Myline OlivasTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not ensure that the Hoyer lift was properly charged while transferring the resident
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 staff and explained the reason for the visit. Administrator Myline Olivas arrived shortly after.

On 08/21/2024, the initial complaint visit was conducted by LPA between approximately 12:20 a.m. - 3:30 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. On 10/24/2024, LPA conducted a subsequent visit from approximately 10:30 a.m. – 3:00 p.m. and conducted physical plant, interviewed staff , families / responsible parties of residents in care and reviewed and obtained copies of additional pertinent documentation relevant to the investigation. Today LPA conducted interviews with staff as well as family / responsible parties.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20240816153518
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: 01/29/2025
NARRATIVE
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It was reported that "Staff did not ensure that the Hoyer lift was properly charged while transferring the resident" as it was alleged that when staff used a Hoyer lift on R3 it was not fully charged and R3 was suspended in the air for 10 minutes. Interviews and records review revealed that on 08/14/2024, R3 was being prepared for a transfer using a hoyer lift with assistance from Staff #1 (S1) and Staff #2 (S2). A family member/responsible party was present in the room at the time. While attempting to lower the hoyer lift to transfer R3 into the bed, the lift became non-operational due to hoyer lift not being fully charged. S1 and S2 contacted Staff #(S3) for assistance and S3 advised S1 and S2 how to operate lift with no power. Staff then raised the bed, placed additional pillows for safety, and manually lowered R3 onto the bed. Staff stated that R3 was suspended in the hoyer lift for approx 5 minutes. On 08/21/2024, 10/24/2024 and 01/29/2025, LPA attempted to contact S1 but was unsuccessful. S1 is no longer employed at the facility. An interview with S2 indicated they did not recall experiencing any issues with operating the hoyer lift during the transfer of R3 on that date. An interview with R3 revealed they did not recall being suspended in the hoyer lift for any extended period. During physical plant inspections, the hoyer lift was found to be fully charged and plugged into an outlet in the living room. There are no residents in care that require the use of a hoyer lift at this time. Based on the information gathered during the investigation, the department has sufficient evidence to confirm this allegation occurred. Therefore, the allegation that "Staff did not ensure that the hoyer lift was properly charged while transferring the resident" has been deemed Substantiated at this time.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 9099-D).Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted, appeal rights discussed and a copy of report issued
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20240816153518
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
87411(d)(3)
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(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirment wa not met as evidence by:
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Administrator agreed to review section cited and provide in-service training with staff regarding proper use of hoyer lift then submit proof of training and statement of understanding to LPA via email by COB 02/14/2025.
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Based on interviews and records review the licensee did not comply with regulation cited as R3 was suspended in their hoyer lift for an extended period of time due to staff failing to demonstrate knowledge for use of hoyer lift, which posed a potential health and safety risk 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: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8