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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191805246
Report Date: 02/23/2022
Date Signed: 02/23/2022 05:33:27 PM

Substantiated


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
10/12/2021 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20211012121229
FACILITY NAME:BEL AIR GUEST HOMEFACILITY NUMBER:
191805246
ADMINISTRATOR:SAMUEL, GALINAFACILITY TYPE:
735
ADDRESS:1440 NO. STANLEY AVENUETELEPHONE:
(323) 876-3370
CITY:LOS ANGELESSTATE: CAZIP CODE:
90046
CAPACITY:64CENSUS: 58DATE:
02/23/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Edgar RamirezTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Facility did not have supervising staff on site.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) LaQueena Lacy conducted an unannounced subsequent complaint visit to the facility on 02/23/2022 at 11:20am for the purpose of providing the investigative findings to the allegation noted above. Upon arrival LPA met with Patricia Gutierrez and explanined the purpose of the visit. A physical plant tour was conducted at 11:23am.

It is alleged that there was no resident supervisor or manager on site at the time the paramedics was dispatched to the facility on 10/08/21 at 1:40am. To investigate the above allegation, on 10/13/2021 at approximately 10:38am between 11:56am LPA began interviews with staff and residents. LPA spoke with six (06) out of sixty (60) clients. Interviews verified that staff #1 (S1) who was working between 11:30am to 8:00am, does not stay in the facility. S1 sleeps in their car until it is time to serve breakfast. During the investigation of another complaint control number 31-AS-20210405172542, conducted by the Community Care Licensing Investigation bureau, S1 was interviewed by investigators Brunelli, and Investigator Santana on 01/01/21 at 4:10pm, S1 admitted that she naps in the car, sets the alarm for every fifteen (15)
Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
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 3
Control Number 31-AS-20211012121229
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: BEL AIR GUEST HOME
FACILITY NUMBER: 191805246
VISIT DATE: 02/23/2022
NARRATIVE
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minutes and leaves the window cracked, to hear what was going on with the residents and has a better view from the car in the parking lot.

On 10/13/21 at 10:31am, LPA obtained facility records pertinent to the investigation. A review of facility staff schedule revealed that S1 works from 11:30pm – 8:00am, seven (7) nights a week, to supervise sixty (60) residents.

On 10/13/21 at 10:05am LPA Lacy inspected the facility inside and out and noted that S1 cannot observe the inside of the facility while sitting in her car in the parking lot.

Based on the information obtained through interviews, observation, and document review there is sufficient information to support the allegation. Therefore, the allegation is deemed Substantiated at this time.

Exit interview conducted. Citations issued. Appeal Rights and Copy of report issued.

SUPERVISOR'S NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20211012121229
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: BEL AIR GUEST HOME
FACILITY NUMBER: 191805246
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/10/2022
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by;
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Licensee provided counseling regarding the importance of being in the facility and providing care and supervision. S1 signed statement that she is to remain in the facility during her work. This citation is cleared during this visit.
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 The licensee did not ensure that facility clients are properly supervised during night shift.
During night shift S1 was sleeping in the car in the parking lot of the facility.
This poses an immediate health and safety risk to clients in care.
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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: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3