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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 195850496
Report Date: 09/26/2025
Date Signed: 09/29/2025 08:40:48 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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/16/2025 and conducted by Evaluator Zabel Chochian
COMPLAINT CONTROL NUMBER: 29-AS-20250616151241
FACILITY NAME:OHANA RECOVERY CENTERFACILITY NUMBER:
195850496
ADMINISTRATOR:DRAKE, MELINDAFACILITY TYPE:
772
ADDRESS:1952 HAZEL NUT COURTTELEPHONE:
(818) 571-9841
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:6CENSUS: 0DATE:
09/26/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Amy Spahr, Clinical DirectorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Licensee did not report changes made in the plan of operation which affect the services to clients
Incomplete client records
Direct care staff do not meet the minimum qualifications required
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Zabel Chochian conducted a subsequent complaint visit to deliver final findings for the above allegations. During today’s visit, LPA met with Amy Spahr. The reason for the visit was explained.

On 06/16/2025, the Department received a complaint regarding the following allegations,
Licensee did not report changes made in the plan of operation which affect the services to clients; Incomplete client records and Direct care staff do not meet the minimum qualifications required.

During the initial complaint visit on 6/18/2025, LPA and staff toured the physical plant areas inside and outside to ensure there are no immediate health and safety hazards and facility is in compliance with Title 22 Regulations. Allegations were discussed and copies of pertinent records relevant to the investigation was requested. To investigate this complaint, LPA conducted a file review and reviewed the California Department of Health Care Services (DHCS) annual review report dated 02/25/2025. (Cont. to LIC9099c)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
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 5
Control Number 29-AS-20250616151241
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OHANA RECOVERY CENTER
FACILITY NUMBER: 195850496
VISIT DATE: 09/26/2025
NARRATIVE
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On the allegation, Licensee did not report changes made to the plan of operation which effect the services to clients – the DHCS annual review confirmed that the facility was unable to provide documented evidence that they provide services which emphasize the development of vocational skills and linkages to services offering employment or job placement. Discrepancies were found in the current policy and procedures used by facility from the initial plan of operation submit. Also, changes in the administration were made without obtaining prior approval. Based on information obtained from credible witness and records review there is sufficient evidence to support the allegation occurred. Therefore, the allegations of is deemed substantiated at this time.

On the allegation of Incomplete client records, during the DHCS annual review, facility was out of compliance with this section based on a review of three (3) client records. The admission agreement in three (3) client record(s) (Client #1, #2, #3) reviewed did not contain documented evidence that it was signed on entry by the client or an authorized representative and program representative; two (2) client record(s) (client#2 and #3) written assessments was not completed on admission. The treatment/ rehabilitation plan in one (1) open client records (client #3) did not contain documented evidence of length of stay needed to accomplish identified goals and methods to evaluate achievement of goals. Discharge summary for two (2) client(s) for (client #4 and client #5) did not contain documented evidence of services provided, goals accomplished, reason and plan for discharge and referral for follow-up plans. The discharge summary for two (2) client(s) for Client #4 and Client #5 did not contain documented evidence that it was prepared with the client. Based on information obtained and records review there is sufficient evidence to support the allegation occurred. Therefore, the allegations of is deemed substantiated at this time.

On the allegation Direct care staff do not meet the minimum qualifications required – during the DHCS annual review on 2/25/25, the facility was unable to provide documented evidence that the staff preparing the admission assessments had received training in the development of the preparation of these documents. Ohana Recovery Center was out of compliance based on a review of in-service training records. The facility was unable to provide documented evidence that the staff preparing the treatment/rehabilitation plans had received training in the development of the preparation of these documents. The facility was unable to provide documented evidence that the staff preparing the discharge summary had received training in the development of the preparation of these documents. Ohana Recovery Center was out of compliance based on a review of personnel records. Eight (8) personnel records for Staff #1-8 did not contain documented evidence that the employee(s) had one (1) year of full-time experience, or its part-time equivalent.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20250616151241
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OHANA RECOVERY CENTER
FACILITY NUMBER: 195850496
VISIT DATE: 09/26/2025
NARRATIVE
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Based on information obtained and records review there is sufficient evidence to support the allegation occurred. Therefore, the allegations of is deemed substantiated at this time.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and / or California Health and Safety Code.

Exit interview conducted. Report was reviewed. A copy and appeal rights were issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20250616151241
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OHANA RECOVERY CENTER
FACILITY NUMBER: 195850496
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2025
Section Cited
CCR
81022(i)
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(i) Any changes in the plan of operation which affect the services to clients shall be subject to licensing agency approval and shall be reported as specified in Section 81061. This requirement is not met as evidence by:
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Facility is closing as of 9/30/2025.
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 Based on interview and records reviewed. Licensee did not obtain prior approval for updates/changes made to the facility's plan operation.
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Type B
09/26/2025
Section Cited
CCR
81070(b)(7)
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CLIENT RECORDS 81070
(b) Each client record shall contain the following information including, but not limited to, the following: (7) A signed copy of the admission agreement specified in Section 81068. This requirement is not met as evidence by:
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Facility is closing as of 9/30/2025.
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Based on records review and interview with credible witness client records records were found incomplete during DHCS annual review on 2/25/25.
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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: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20250616151241
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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OHANA RECOVERY CENTER
FACILITY NUMBER: 195850496
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2025
Section Cited
CCR
81065(n)
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(n) All direct care staff shall meet the minimum qualifications as set forth in California Code of Regulations, Title 9, Division 1, Chapter 3, Article 3.5, Sections 532.6(h) and (i). This requirement is not met as evidence by:
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Facility is closing 09/30/2025
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Based on records review and interview with credible witness staff records were found incomplete during DHCS annual review on 2/25/25.
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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: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5