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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850239
Report Date: 01/07/2025
Date Signed: 01/07/2025 04:46:41 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: 5DATE:
01/07/2025
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Kina NkumbulaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff is overcharging a resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint visit for the above allegation. LPA arrived to the facility at 09:46 AM 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 today’s visit 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.

Continued on LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
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 6
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: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/21/2025
Section Cited
CCR
87464(e)
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87464 Basic Services
(e) If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident.
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 interview and record review the licensee did not comply with the section cited above as a late fee of $75 was charged to an SSI resident in addition to the cost of basic services which poses a potential personal rights risk to clients in care.
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Type B
01/21/2025
Section Cited
CCR
87507(f)
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87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.
This requirement is not met as evidenced by:
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Licensee will submit a statement of understanding confirming that they will adhere to all aspects of the resident's admission agreement. Additionally, the licensee will submit a copy of the breakdown of charges for R1.
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Based on interview and record review the licensee did not comply with the section cited above as an itemized list of extra food service charges was not provided to the party responsible for R1's payments to the facility 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: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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: 5DATE:
01/07/2025
UNANNOUNCEDTIME BEGAN:
09:46 AM
MET WITH:Kina NkumbulaTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not provide resident with an admission agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Trevor Byrne conducted an unannounced complaint visit for the above allegation. LPA arrived to the facility at 09:46 AM 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 today’s visit 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.

Continued on LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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: 01/07/2025
NARRATIVE
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The allegation of “Staff did not provide resident with an admission agreement.” alleges that R1 was not provided with a copy of their admission agreement. LPA interviewed R1 who stated that they remember the Administrator offering them a copy of the admission agreement at the time it was signed but they declined the offer of a copy as it was stored in their file at the facility. During the interview with the Administrator, they stated that copies of all signed documents are offered to the residents at the time they are signed. Additionally, the Administrator stated that R1 never asked for a copy of their admission agreement. 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 of Staff did not provide resident with an admission agreement. Therefore, the allegation is deemed Unsubstantiated at this time.

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: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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: 01/07/2025
NARRATIVE
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The allegation of “Staff is overcharging a resident in care.” alleges that facility is over-charging Resident #1 (R1) for basic services. LPA Byrne interviewed Witness #1 (W1), W1 stated that R1 has been charged a monthly rate of $1492.82. PIN 23-20-CCLD titled “ESTIMATED SSI/SSP PAYMENT STANDARDS EFFECTIVE JANUARY 1, 2024” states that the approved amount payable for basic services for SSI recipients for the year of 2024 is not to exceed $1398.07. LPA Byrne interviewed the facility Administrator who stated that for the year of 2024 R1 was charged a flat rate of $1400.00 for basic services. The Administrator stated that the additional $92.82 is being charged as a combination of: a $75 late fee for payment received after the first of the month, a $50 monthly haircut fee, and additional snacks ordered by the residents that are not included on the facility’s menu. Interviews with R1 and Resident #2 (R2) revealed that haircuts are provided every 4-5 months or as needed. R1 and R2 confirmed that they order snacks from the Administrator and R2 was aware of the extra charges associated with ordering items not on the facility’s menu. LPA Byrne reviewed the resident’s admission agreement which states, “If requested, special food products purchased for an individual resident will be itemized on a monthly statement and charged at facility’s cost.” The facility Administrator stated that they have not provided an itemized lists of charges to those responsible for R1’s payments to the facility. Additionally, the Administrator stated that they have no receipts of the haircuts being provided to the residents as it was a cash transaction between the facility and a third-party vendor. Based on the information obtained during interviews and record review there is sufficient evidence to support the allegation of Staff is overcharging a resident in care. 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 Kina Nkumbula to sign this report on their behalf. The report was read to the facility administrator via telephone call.

The following deficiencies were 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: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6