Complaint Investigation Report

405850052-8-20-2021-29-AS-KBUY-C7BQ39-20210929114821

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CCLD Regional Office , 21731 VENTURA BLVD. #250

This is an official report of an unannounced visit/investigation of a complaint received in our office on

08/19/2021 and conducted by Evaluator Darlene Chavez

COMPLAINT CONTROL NUMBER: 29-AS-20210819140101

Facility is operating beyond the terms and conditions of the license

Licensing Program Analyst (LPA) Chavez conducted a 10-day complaint investigation visit to the facility above. LPA met with caregiver Lorraine Hurst and explained the reason for the visit.

It was reported to Community Care Licensing (CCL) that the facility above was over capacity. LPA verified census with Licensee/Administrator to be 13. CCL received an application from the Licensee for an increase of capacity; however, the application has not been approved due to documentation pending from the Licensee. The facility license is authorized for a capacity of 12, therefore the facility is not in compliance with regulation requirements. LPA requested Licensee to complete the application documentation and submit to CCL as soon as possible. LPA also instructed Licensee to immediately move one resident to another facility with approval from resident’s family or person of responsibility. Based on the information obtained, the allegation "Facility is operating beyond the terms and conditions of the license" is Substantiated.

Exit interview conducted, deficiency cited, report and appeal rights emailed to Licensee.