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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197600256
Report Date: 09/10/2021
Date Signed: 09/10/2021 03:06:04 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2021 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20210907162704
FACILITY NAME:EUNICE HOMEFACILITY NUMBER:
197600256
ADMINISTRATOR:AGBEDE, SONNYFACILITY TYPE:
735
ADDRESS:11611 BALBOA BLVD.TELEPHONE:
(818) 368-9242
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 6DATE:
09/10/2021
UNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Malina Biluan/ House ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Resident eloped from the facility

Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, Arrived at the facility in response to the above mentioned allegations. LPA was greeted at the door by facility staff and all COVID-19 protocols were followed and LPA's temperature was taken. LPA explained the reason for the visit.

Allegation 1. Resident eloped from the facility
On 9/3/2021, LPA received an incident report which indicated, that on the night of 9/2/2021 the resident in question (R1) did elope from the facility. Facility staff called 911 and began searching for R1. R1's responsible party was notified and staff and police attempted in the search for R1. At approximately 6:37 PM, on 9/3/21, R1 was located at a local hospital and was unharmed.

Based on incident reports received and from confirmation from facility staff, this allegation is deemed to be substantiated.
Continues on LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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 31-AS-20210907162704
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EUNICE HOME
FACILITY NUMBER: 197600256
VISIT DATE: 09/10/2021
NARRATIVE
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Allegation 2. Facility is in disrepair
LPA arrived at the home at approximately 12:00 PM. Upon arrival, LPA did observe that the front gate to the home is missing a self latching lock, and the gate does not close. LPA then came to the front door of the house and was allowed entry by facility staff. While the LPA came into the home, the LPA observed that the hinges to the front door were loose and the door would not close properly. LPA brought this to the attention of staff at approximately 1:00 PM.
Based on staff and LPA observation, this allegation is deemed to be substantiated at this time.


Exit interview conducted, deficiencies cited, report issued and appeal rights discussed.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2021 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20210907162704

FACILITY NAME:EUNICE HOMEFACILITY NUMBER:
197600256
ADMINISTRATOR:AGBEDE, SONNYFACILITY TYPE:
735
ADDRESS:11611 BALBOA BLVD.TELEPHONE:
(818) 368-9242
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 6DATE:
09/10/2021
UNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility is operating out of capacity

Facility staff was over medicating resident

Resident lost an excessive amount of weight while in care
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA), Patrick Shanahan, Arrived at the facility in response to the above mentioned allegations. LPA was greeted at the door by facility staff and all COVID-19 protocols were followed and LPA's temperature was taken. LPA explained the reason for the visit.

Allegation 1. Facility is operating out of capacity.
LPA arrived at the home and began touring the inside of the home at approximately 12:20 PM. LPA observed that there were 6 residents in care and 3 staff observing and assisting residents. The home has 2 shared rooms and 2 private rooms. The LPA observed 6 beds and 6 residents at the facility. Staff were interviewed at about 1:00 PM and all staff indicated that there were 6 residents residing at the home. The facility is licensed for 6 residents. There were no other clients or bedding observed throughout the facility, to indicated additional residents.
Based on LPA observations and staff interviews, this allegation is deemed unsubstantiated.
Continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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 5
Control Number 31-AS-20210907162704
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EUNICE HOME
FACILITY NUMBER: 197600256
VISIT DATE: 09/10/2021
NARRATIVE
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Allegation 2. Facility staff was over medicating resident
At about 1:25 PM, LPA and staff conducted a medication count of 3 out of the 6 residents. All the resident medications are in bubble packs and LPA and staff were able to determine that all medications added up to the correct amount and are dispensed properly. Staff interviewed confirmed that all medication is given as prescribed. Medication documentation and the medications at the facility all added up to the correct amount.
Based on the medication documentation and the medication count, this allegation is deemed to be unsubstantiated at this time.

Allegation 3. Resident lost an excessive amount of weight while in care
At approximately 1:00PM, staff was able to gather the weight records for the resident in question (R1). LPA and staff then went through the weight records for R1. Weight records for 2021 indicated that R1's weight had fluctuated between 156 LBS to 140 LBS, but there was no excessive weight loss in-between months at the home. Weight records for 2019 indicated a weight fluctuating between 139 LBS to 132 LBS.
Based on weight records review for R1 indicating that there was no excessive weight loss, this allegation is deemed to be unsubstantiated at this time.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20210907162704
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: EUNICE HOME
FACILITY NUMBER: 197600256
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2021
Section Cited
CCR
80078(a)
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80078(a) Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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The administrator agrees to have door alarms placed on all doors so that staff is aware when doors open and close. Receipts and pictures will be submitted to LPA as POC.
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Based on staff admission and an incident report received in the ccl office, the licensee did not prevent R1 from leaving the facility unattended, which posed an immediate risk to the health and safety on residents in care.
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Type B
09/17/2021
Section Cited
CCR
80087
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80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
This requirement is not met as evidence by:
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The administrator agrees to fix the front door and the front gate and submit pictures or an invoice of the correction to the LPA by the POC date.
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Based on LPA and staff observation, the licensee did not ensure the front door is able to close or the front gate to latch, which poses a potential risk to residents 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5