<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290706
Report Date: 02/15/2023
Date Signed: 02/16/2023 04:58:13 PM

Document Has Been Signed on 02/16/2023 04:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME:HAMILTON HOUSEFACILITY NUMBER:
191290706
ADMINISTRATOR:PETERSON, JANICEFACILITY TYPE:
735
ADDRESS:739 W. GLENOAKS BLVD.TELEPHONE:
(818) 502-9188
CITY:GLENDALESTATE: CAZIP CODE:
91202
CAPACITY: 11CENSUS: 9DATE:
02/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Elizabeth Caballero, Staff memberTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced case management visit at this facility to issue deficiency in conjunction with complaint control # 28-AS-20230210144317, wherein during the course of investigation regarding this complaint, LPA observed the following:
  • In October 2022, Staff #2 (S2) was assigned to be a temporary Administrator for this facility.
  • As of February 2023, S2 was officially assigned to be the Administrator for this facility.
  • LPA was informed that all paperwork was already submitted/mailed to Woodland Hills Regional Office.
  • LPA spoke with S2 at 1:36pm and requested all documents to be emailed. At 2:27pm, LPA contacted S2 to follow up regarding the documents.
  • S2 informed LPA that all documents will be requested through this facility company's Human Resources.
  • LPA reviewed S2’s facility file at 2:35pm and it was incomplete.
  • During the interview with S1, S2 and S3 LPA was informed that the facility had numerous Administrators from the year of 2000 to present. In addition, the last Administrator on file has not been working for this facility since 2000.
Thus, the facility failed to update and inform the Regional Office of new Administrator (change) and or Designee.

Citation issued on LIC809-D and appeal rights discussed.

Exit interview conducted. Copy of this report issued
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 02/16/2023 04:58 PM - It Cannot Be Edited


Created By: Angela Panushkina On 02/15/2023 at 03:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: HAMILTON HOUSE
FACILITY NUMBER: 191290706

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2023
Section Cited
CCR
85061(b)(1-3)(A)

1
2
3
4
5
6
7
85061 Reporting Requirements
b) The licensee shall notify the licensing agency, in writing, within 30 days of a change of administrator. 1)Name... 2) Date... 3) Des- cription... A) A photocopy of documentation...


This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The licensee will provide the LIC 308, LIC 500 specifying working hours, the LIC 501, a copy of the Administrator Certificate, an active criminal record clearance, and a copy of the board resolution or the date of the next board meeting and the resolution. All documents shall be submitted by POC date.
8
9
10
11
12
13
14
Based on record review and interview, the licensee did not comply with the section cited above in the change of administrator which poses a potential Haealth, Saftey, or Prsonal Rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2