197600256-3-1-2022-31-AS-NGID-CD7MMZ-20220405094446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197600256
Report Date: 03/01/2022
Date Signed: 03/01/2022 01:49:59 PM

Unsubstantiated

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
02/28/2022 and conducted by Evaluator Patrick Shanahan

COMPLAINT CONTROL NUMBER: 31-AS-20220228135917

FACILITY NAME:	EUNICE HOME		FACILITY NUMBER:	197600256
ADMINISTRATOR:	AGBEDE, SONNY		FACILITY TYPE:	735
ADDRESS:	11611 BALBOA BLVD.		TELEPHONE:	(818) 368-9242
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 6	DATE:	03/01/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Malina Biluan/ House Manager		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident fell while in care.

Resident was left on floor for an extended period of time.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in response to the above mentioned complaint allegations. LPA was greeted by facility staff and all COVID-19 protocols were followed before allowing the LPA entrance.
Allegation 1. Resident Fell While in Care
LPA was able to interview the resident in question (R1) and staff members who were present at the time of the incident. R1 confirmed that R1 had fallen from R1's bed. R1 was interviewed at about 11:15 AM. Staff interviewed also confirmed that R1 had fallen from R1's bed. Documentation reviewed indicated that R1 does not require a one on one staff member and is able to sleep or be in R1's room alone. Staff indicated that R1 was assisted back to bed after breakfast without incident. R1 attempted to get up after R1's nap and lost balance. Although a fall did occur, the fall was un-witnessed while R1 was alone in R1's room and was not due to the negligence of staff. Based on information received through interviews and documentation review, this allegation is deemed UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

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 31-AS-20220228135917

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: 03/01/2022

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

Allegation 2 - Resident was left on floor for an extended period of time.
LPA was able to interview R1 and staff present at the time of the incident in order to come to findings for this allegation. LPA was also able to review and gather pertinent documentation during this visit. R1 indicated that R1 did have a fall but could not recall at what time the fall had occurred or how long it took staff to assist the resident. R1 did indicate that facility staff did assist R1 up from the floor. Staff interviewed indicated that R1 appeared tired after breakfast on the day in question. Staff stated that R1 had requested to go back to bed at about 9:00 AM, after R1 had finished breakfast. Staff assisted the resident to bed and left the room. Both staff who were present on the day of the fall indicated that checks were preformed on the resident about every 30 min. At about 10:45 AM, staff heard R1 call for help and the resident was assisted up from the fall. All staff interviewed indicated that there is no way that a client could be left on the floor for an extended period of time. Staff present at the time of the fall indicated that they were able to assist the resident up within minuets of the fall.
Based on information received from interviews and a review of pertinent documentation, this allegation is deemed UNSUBSTANTIATED.

Exit interview conducted and report issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2