191222021-3-14-2023-31-AS-NGID-CQ6JZK-20230322072936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191222021
Report Date: 03/14/2023
Date Signed: 03/14/2023 12:13:50 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/06/2023 and conducted by Evaluator Shira Stamps

COMPLAINT CONTROL NUMBER: 31-AS-20230306151433

FACILITY NAME:	MAHARLIKA HOME II		FACILITY NUMBER:	191222021
ADMINISTRATOR:	LEDESMA, NOELLIE		FACILITY TYPE:	735
ADDRESS:	17345 BURTON STREET		TELEPHONE:	(818) 708-0627
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 5	DATE:	03/14/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Noellie Ledesma, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident physically assaulted another resident due to lack of supervision.

INVESTIGATION FINDINGS:

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At 10:00 am Licensing Program Analyst (LPA) Shira Stamps conducted an unannounced complaint visit to investigate the allegation above. LPA was greeted by Staff, who granted access to the facility. LPA explained the reason for the visit to the Administrator. At 10:15am, LPA conducted a tour of the facility and interviewed staff and clients.

Allegation: Resident physically assaulted another resident due to lack of supervision.
It is alleged that client one (C1) was hit by C1’s roommate (C2), leaving discoloration above C1’s left eye due to a lack of supervision from staff. LPA interviewed three (3) staff members. Staff interviews indicated that C2 woke up in the middle of night yelling that C1 had stolen C2’s wallet. Staff interviews indicated night staff was sitting in the bedroom of another client down the hall before the incident occurred. Once staff heard yelling it was indicated that staff immediately went into the room and separated the clients.

CONTINUED...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230306151433

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MAHARLIKA HOME II	FACILITY NUMBER: 191222021
	VISIT DATE: 03/14/2023

NARRATIVE

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LPA reviewed the incident report sent to Community Care Licensing on 3/6/23 indicating staff heard yelling from C1’s room and immediately separated the clients. The incident report also indicated one staff stayed with C2 to calm C2 down. LPA observed the distance between the two bedrooms and the rooms are located closely together so that a person could hear sound in the next room. The bedrooms are also located closely together where it would only take seconds to move into the next room. From 11:00am-11:45am, LPA interviewed three (3) out of five (5) clients. Client interviews indicated C2 was upset because C2 thought C1 stole their wallet. It was indicated that staff came to assists the clients in their bedrooms when the incident occurred. Interviews indicated staff came immediately to help C1 and C2 when staff heard C2 yelling at C1 in the middle of the night. Observation of the physical plant indicated the rooms are located closely together and staff did not have to walk far to enter into the bedroom of C1 and C2. Based on interviews, observation of the physical plant, and document review the allegation, “Resident physically assaulted another resident due to lack of supervision,” is deemed unsubstantiated.

Exit interview conducted. Report delivered to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2023

LIC9099 (FAS) - (06/04)

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