195850239-10-16-2024-29-AS-KLOZ-DABVKA-20241023163000

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 195850239
Report Date: 10/16/2024
Date Signed: 10/16/2024 05:07:22 PM

Unsubstantiated

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
09/24/2024 and conducted by Evaluator Trevor Byrne

COMPLAINT CONTROL NUMBER: 29-AS-20240924100206

FACILITY NAME:	SILVER LIGHT CARE		FACILITY NUMBER:	195850239
ADMINISTRATOR:	KHACHATRYAN, ELBA		FACILITY TYPE:	740
ADDRESS:	8201 VANTAGE AVENUE		TELEPHONE:	(747) 228-4111
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	10/16/2024
		UNANNOUNCED	TIME BEGAN:	02:51 PM
MET WITH:	Kina Nkumbula		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not provide assistance in meeting resident's medical needs
Facility staff denied resident access to personal belongings

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced subsequent complaint visit for the above allegations. LPA arrived to the facility at 02:51 PM and met with facility staff Kina 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 10/02/2024, the LPA conducted a physical plant tour, conducted interviews with the administrator, one (1) staff member, and two (2) residents between 02:49 PM and 04:20 PM. LPA obtained copies of pertinent documents relevant to the investigation. During today’s visit on 10/16/2024 LPA conducted a brief physical plant tour, conducted an additional staff interview with Staff #1 (S1) and delivered the complaint investigation findings.

Continued on LIC-9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

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-20240924100206

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: 10/16/2024

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
26
27
28
29
30
31
32

The allegation of “Facility staff did not provide assistance in meeting resident's medical needs” alleges that the facility failed to call 911 in response to a medical emergency for Resident #1 (R1). LPA Byrne interviewed Staff #1 (S1) who stated that on 09/10/2024 R1 sat in a chair in the living room of the facility and began exclaiming, “I am having a seizure, I’m having a seizure.” S1 told R1 to stay calm and began putting on gloves to assist. R1 then got out of the chair and walked to the backyard of the facility before S1 could put on the gloves. S1 was then informed that R1 had called 911 for themselves. S1 confirmed that they heard the sirens of EMS approaching and stated that R1 came back inside the facility and returned to the living room and waited for EMS to arrive. S1 confirmed that R1 had not expressed any complaints of chest pain or anxiety prior to the arrival of EMS and had not asked S1 for any additional assistance. Based on the information obtained during the interview and record review although the allegation may have happened or is valid there is insufficient evidence to support the allegation that facility staff did not provide assistance in meeting resident's medical needs. Therefore, the allegation is deemed Unsubstantiated at this time.

The allegation of “Facility staff denied resident access to personal belongings” alleges that facility staff withheld R1’s personal belongings after they were requested. During the initial complaint investigation LPA Byrne interviewed S1 who was alleged to have withheld R1’s belongings. S1 stated that R1 had asked the facility to centrally store their driver’s license and debit cards for safekeeping as they were afraid of losing the items. S1 stated that on 09/10/2024 R1 had called 911. Once first responders arrived R1 requested to be transported to the hospital and requested to bring their driver’s license and debit card. S1 stated that they initially did not provide the items as they required permission from the administrator. S1 stated that they reached out to the facility administrator to ask for guidance. After speaking with the facility administrator via telephone call the administrator advised S1 to provide the personal belongings. S1 then provided the driver’s license and debit card to R1 to take with them. S1 stated that the approximate timeframe from when the request for the items was made to when they were provided was about five (5) to ten (10) minutes. S1 stated that the whole interaction with EMS was around thirty (30) minutes. Based on the information obtained during the interview although the allegation may have happened or is valid there is insufficient evidence to support the allegation that facility staff denied resident access to personal belongings. Therefore, the allegation is deemed Unsubstantiated at this time.

Continued on LIC-9099C

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 29-AS-20240924100206

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: 10/16/2024

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 26 27 28 29 30 31 32	The facility administrator was unable to come to the facility at the time of the investigation but has designated staff member Kina Nkumbula to sign this report on their behalf. The report was read to the facility administrator via telephone call. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3