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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850239
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:51:36 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
01/03/2025 and conducted by Evaluator Trevor Byrne
COMPLAINT CONTROL NUMBER: 29-AS-20250103170627
FACILITY NAME:SILVER LIGHT CAREFACILITY NUMBER:
195850239
ADMINISTRATOR:KHACHATRYAN, ELBAFACILITY TYPE:
740
ADDRESS:8201 VANTAGE AVENUETELEPHONE:
(747) 228-4111
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:6CENSUS: 6DATE:
01/15/2025
UNANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Keyna NkumbulaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced follow-up complaint visit for the above allegation. LPA arrived to the facility at 02:17 PM and met with facility staff Keyna Nkumbula. Facility staff contacted the facility administrator via telephone call. The facility administrator was unable to come to the facility at the time of the investigation. Entrance interview conducted and the reason for the visit was explained.

During the initial complaint visit on 01/07/2025 between 09:48 AM and 02:00 PM LPA conducted a physical plant tour, reviewed five (5) resident files, interviewed four (4) residents, one (1) staff member, and the facility administrator. During today’s visit between 02:17 PM and 02:30 PM LPA conducted a brief physical plant tour, collected copies of relevant documentation, and interviewed one (1) staff member.

Continued on LIC 9099C.

Substantiated
Estimated Days of Completion: 7
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
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 29-AS-20250103170627
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: SILVER LIGHT CARE
FACILITY NUMBER: 195850239
VISIT DATE: 01/15/2025
NARRATIVE
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The allegation of “Staff did not safeguard resident's personal belongings.” alleges that facility staff signed for the delivery of a hospital bed and wheelchair for Resident #1 (R1) which R1 never received and the items are now missing. On 01/07/2025 LPA received an email from Witness #1 (W1). The email contained a photocopy of two (2) delivery tickets dated 09/26/2023 and 10/05/2023 from MedLife MediCal Supply Inc. The delivery ticket dated 09/26/2023 specified that the items delivered were: a standard wheelchair and additional accessories for the wheelchair. The delivery ticket dated 10/05/2023 specified that the items delivered were: a hospital bed and additional accessories for the hospital bed. LPA Byrne reviewed the bottom of the delivery ticket. This section stated, “I confirm that Medicare or my insurance has not purchased or rented similar items to the ones being delivered unto me today…” LPA confirmed that the name at the bottom of the delivery ticket was Keyna Kumbula (Keyna Nkumbula) (S1) and the signature matched that of previous reports signed by S1. The reason given for why the patient (R1) could not sign the delivery ticket was, “Patient Unable”. During today's interview with S1 LPA Byrne showed them the signature at the bottom of the delivery document. S1 confirmed that the signature matched their own. Based on the information obtained during interviews and record review there is sufficient evidence to support the allegation of Staff did not safeguard resident's personal belongings. Therefore, the allegation is deemed Substantiated at this time.

The facility administrator was unable to come to the facility at the time of the investigation but has designated staff member Keyna Nkumbula to sign this report on their behalf. The report was read to the facility administrator via telephone call.

The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250103170627
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: SILVER LIGHT CARE
FACILITY NUMBER: 195850239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2025
Section Cited
CCR
87468.2(a)(25)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1...
(25) To protection of their property from theft or loss...
This requirement is not met as evidenced by:
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Licensee will submit their plan on how they will correct this citation to CCLD no later than POC due date.
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Based on record review and interview the licensee did not comply with the section cited above as a hospital bed delivery was signed for by facility staff but the facility is unable to locate the hospital bed that was signed for which poses a potential personal rights 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.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3