191290706-6-12-2023-31-AS-TAGD-CYNP8L-20231219100543

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191290706
Report Date: 06/12/2023
Date Signed: 06/12/2023 01:26:42 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
06/05/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20230605110215

FACILITY NAME:	HAMILTON HOUSE		FACILITY NUMBER:	191290706
ADMINISTRATOR:	PETERSON, JANICE		FACILITY TYPE:	735
ADDRESS:	739 W. GLENOAKS BLVD.		TELEPHONE:	(818) 502-9188
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91202
CAPACITY:	11	CENSUS: 9	DATE:	06/12/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Carlos Correa - Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Client's room door is in disrepair

Staff did not keep facility free of pests

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Gary Tan conducted an unannonced complaint visit at this facility to investigate the above allegation. LPA met with staff Cathy Solorzano who called the administrator and arrived about 1 1/2 hour later.

LPA conducted physical plant tour at 9:35 AM, requested copies of facility documents relevant to the investigation at 10:00 AM and interviewed staff and residents between 10:15 AM to 12:30 PM. Regarding the allegation that Client's room door is in disrepair, it was alleged that the bedroom door lock of Resident #1 (R1) is in disrepair. LPA's observation during physical plant tour at 9:35 AM revealed that the lock on R1's bedroom was not working, the latch does not get in the latch plate as it did not have a hole in it and R1 and roommate were unable to lock the door.

(continued on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

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-20230605110215

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAMILTON HOUSE	FACILITY NUMBER: 191290706
	VISIT DATE: 06/12/2023

NARRATIVE

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(continued from LIC 9099)

Regarding the allegation that the Staff did not keep facility free of pests, it was alleged that there are mice and bed bugs at the facility. During physical plant tour at 9:35 AM, LPA did not observe any mice and/or bed bugs at the facility. LPA's interview with staff also revealed that there have been continuing treatment for bed bugs at the facility, LPA's interview with resident however revealed that a resident saw a mouse on own room and saw mice droppings inside the facility.

Based on the information gathered during this visit, the allegations are deemed substantiated at this time.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230605110215

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAMILTON HOUSE	FACILITY NUMBER: 191290706
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/14/2023 Section Cited CCR 80072(a)(2)	1 2 3 4 5 6 7	To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to call the Pest Control company and treat the facility of pests inside and out. Administrator agreed to send a copy of the invoice of pest control treatments on or before the POC date
	8 9 10 11 12 13 14	Based on LPA observation and interview, Licensee failed to ensure that the facility is free of pests including mice, bedbugs, etc., This poses an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14
Type B 06/19/2023 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The administrator agreed to do the repair immediately and submit proof of correction including invoice and photos of repaired doors on or before the POC date.
	8 9 10 11 12 13 14	Based on LPA observation and interview Licensee failed to ensure that the facility is in good repair at all times. This poses a potential health and safety risk to the residents in care.	8 9 10 11 12 13 14

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: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC9099 (FAS) - (06/04)

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