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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850230
Report Date: 09/15/2026
Date Signed: 09/15/2026 01:13:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
09/08/2026 and conducted by Evaluator Melisa Rankin
COMPLAINT CONTROL NUMBER: 29-AS-20260908130120
FACILITY NAME:A CASA RANCHFACILITY NUMBER:
425850230
ADMINISTRATOR:SORIANO, APRILYN AFACILITY TYPE:
740
ADDRESS:502 N Ranch STTELEPHONE:
(650) 544-1485
CITY:Santa MariaSTATE: CAZIP CODE:
934543853
CAPACITY:6CENSUS: DATE:
09/15/2026
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff violated clients personal rights.
Staff failed to prevent fall
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rankin conducted a subsequent complaint visit to the facility above to issue final findings. Upon arrival, LPA met with Administrator Designee Maria Cuevas/Sola and explained the reason for the visit.

During the initial visit on 09/9/26 LPA interviewed administrator, designee administrator, staff, and residents and conducted a physical plant tour. During the investigation LPA reviewed relevant documentation and took images of areas of concern.

On the allegation: Staff violated clients personal rights.

It was alleged that on the morning of 9/7/2026, staff were pushing Resident 1 (R1) backwards in their wheelchair out of the bathroom area when the wheelchair became stuck on an object, causing R1 to fall backwards. During this time it was alleged that a second resident attempted to assist staff during the fall on 9/7/2026 and staff yelled “Get away!” at the resident, frightening them. It was also alleged that on either 8/24/2026 or 8/31/2026,
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
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-20260908130120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A CASA RANCH
FACILITY NUMBER: 425850230
VISIT DATE: 09/15/2026
NARRATIVE
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staff was observed attempting to transfer R1 from their wheelchair to a chair, during which staff dropped R1 who then fell to their knees. It was also stated that residents were not receiving PRN medication when requested and that residents were left in soiled clothing for extended periods.

Regarding the 9/7/26 incident, staff demonstrated that R1 had been seated on a walker with a built in seat rather than a wheelchair. When maneuvering the resident over a raised ledge between the bathroom and hallway, R1 fell backwards. Use of the walker as transport equipment was not appropriate and does not meet safe transfer practices.
It was alleged that resident was dizzy and their head hurt, 911 was called, R1 was later discharged from the hospital with diagnosis of “closed head injury and scalp contusion.” Instruction to take Tylenol for pain.

Home Health Nurse notes dated 9/1/26 documented R1 complaining of bilateral knee pain shortly after the alleged fall during a transfer supporting the possibility of a fall during transfer. Interviews with residents and staff could not verify a fall occurred.

The LPA conducted resident interviews during visits on 9/9/26 and 9/15/26. One resident stated that a staff member sometimes raises their voice due to having a naturally loud tone. Some residents reported hearing staff raise their voice. Interviews done with other individuals involved in the oversight of the facility admitted that this has been brought up before, providing a history supporting the allegation that the staff member could have yelled at residents on 9/7/26. It is unclear if the yelling was for urgency or directed in anger. Discussion with staff and designee about urging staff take their time off and ensure they are able to maintain their professionalism with residents and visitors.

An audit of Medication Administration Records (MARs) showed that PRN medications were not consistently documented, and some PRN medications did not match their count therefore could not be explained when they were given. Due to incomplete documentation, the LPA was unable to verify when PRN medications were administered.

On the allegation that residents are not assisted with changing soiled clothing, it could not be verified but was discussed with residents and staff. It was confirmed that staff have to assist R1 to use the restroom as they are unable to get up on their own and that most residents wear some form of brief.
Continue on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 29-AS-20260908130120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A CASA RANCH
FACILITY NUMBER: 425850230
VISIT DATE: 09/15/2026
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Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D).

Based on interviews and record review, the preponderance of evidence that the facility has violated the personal rights of residents in care has been met. Therefore, that allegation is SUBSTANTIATED.

On the allegation: Staff failed to prevent fall

It was alleged that on the morning of 9/7/2026 , staff were pushing Resident 1’s (R1) backwards in their wheelchair out of the bathroom area. The wheelchair became stuck on an object, causing R1 to fall backwards.

On 9/8/26, the facility submitted an incident report as required, describing the incident referenced in the complaint.

During the visit on 9/9/2026, the LPA asked staff to demonstrate what had occurred. Staff clarified that R1 had been seated in a walker with a built in seat, not a wheelchair. Staff demonstrated that a raised ledge between the bathroom and hallway required added force to maneuver the resident over it. When staff applied extra force, R1 began to fall backwards while seated in the walker. R1 hit their head on the floor during this event.

It was stated that the resident was dizzy and their head hurt, 911 was called, R1 was later discharged from the hospital with diagnosis of “closed head injury and scalp contusion.” Instructed to take Tylenol for pain.

During interviews with the administrator/licensee and designee, it was stated that the owner had recently renovated the restroom. The renovation resulted in a height difference between the restroom tile and the hallway wood flooring. To cover this area, the installer placed a raised three inch wide metal threshold, the threshold has a small slope and a lift of approximately ½ inch in height. The LPA observed that the ledge presents a safety risk for residents, as it may cause tripping and is particularly hazardous for individuals using walkers or with impaired eyesight.
Continue on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20260908130120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: A CASA RANCH
FACILITY NUMBER: 425850230
VISIT DATE: 09/15/2026
NARRATIVE
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Based on the interviews, observation, and record review there is a preponderance of evidence that R1 did fall while being transported due to inappropriate usage of equipment and the ledge installed therefore the allegation is SUBSTANTIATED at this time.

Report was discussed with designee, copy of appeal rights and the report were printed and provided to designee.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20260908130120
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A CASA RANCH
FACILITY NUMBER: 425850230
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2026
Section Cited
CCR
87307(d)(2)(6)
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87307 Personal Accommodations and Services(d)The following space and safety provisions shall apply to all facilities:
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. (6)All…indoor passageways…shall be kept free of obstruction.
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The licensee must correct the flooring transition between the hallway and restroom to eliminate the raised ledge that creates a safety hazard for residents, staff, and visitors.

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This requirement is not met as evidenced by:
Based on interview, observation, and record review, the licensee did not comply with the section cited above as Resident #1 (R1) sustained a fall due to the updated maintenance of the facility creating a hazard for transportation. This poses an immediate health and safety risk to people in care.
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 The licensee shall repair, modify, or replace the threshold so that it is level and safe for mobility devices. Proof of correction, including photographs and/or invoices, must be submitted to the Department by the POC due date.
Type B
09/20/2026
Section Cited
CCR
97468.2(4)
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87468.2 Additional Personal Rights...(a)In addition to the rights listed in Section 87468.1, Personal Rights...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Documentation of training for proper transfer techniques and proper equipment usage as well as a review of all medication requirements. The medication training will be documented on sign in sheets and topics and training references used will be submitted to LPA via email by 9/20/26.
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This requirement is not met as evidenced by:
Based on interview and record review, the licensee did not comply with the section cited above as Resident #1 (R1) was transported using incorrect equipment and procedures, and medications were not documented as required. This poses a potential health and safety risk to people in care.
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 Administrator will schedule a training from a medical professional on proper transfer techniques and equipment usage, the date of the scheduled training must be provided to LPA by 9/20/26 and there training, if possible, must occur within 2 weeks, documentation of who was trained and the material used will be submitted via email to the LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2026
LIC9099 (FAS) - (06/04)
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