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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850306
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:01:39 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
05/09/2024 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20240509112359
FACILITY NAME:AAA JERUSALEM STARSFACILITY NUMBER:
195850306
ADMINISTRATOR:SOHEILA NOROOZIFACILITY TYPE:
740
ADDRESS:5945 CAPISTRANO AVETELEPHONE:
(818) 888-1706
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 6DATE:
05/16/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Kristina Adamyan, LicenseeTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff are not ensuring a safe environment for resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 1:33 p.m., the LPA met with staff and explained the reason for the visit. At 1:50 p.m., the Licensee, Kristina Adamyan arrived at the facility.

Between 1:51 p.m. and 2:23 p.m., the LPA conducted interviews with the Licensee, one (1) staff and five (5) residents. At 1:55 p.m., the LPA obtained copies of pertinent documents. At 1:57 p.m., the LPA along with the Licensee conducted a physical plant tour.

Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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 2
Control Number 29-AS-20240509112359
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: AAA JERUSALEM STARS
FACILITY NUMBER: 195850306
VISIT DATE: 05/16/2024
NARRATIVE
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Regarding the allegation: Staff are not ensuring a safe environment for resident in care. It was alleged that Resident #1 (R1) felt unsafe due to feeling a hand on their neck while sleeping but when R1 turned on the lights in the room, R1 did not see a person in their room. During the time of the visit, the LPA conducted interviews with five (5) residents, including R1. The interviews revealed that the residents feel safe at the facility and feel well taken care of. No safety concerns were brought up during the resident interviews. Staff interview revealed that staff ensure that front and back doors remain locked. Staff stated that they check on residents every two (2) hours during the night to ensure the wellbeing of the residents. Licensee interview revealed that the facility has cameras in the common areas, and throughout the exterior perimeter of the facility for safety reasons. The Licensee stated that herself and her staff are always checking on the health and safety of all the residents in care. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2