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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197600690
Report Date: 06/01/2023
Date Signed: 06/01/2023 01:36:33 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
05/25/2023 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20230525160102
FACILITY NAME:THERAPEUTIC LIVING CENTERS FOR THE BLINDFACILITY NUMBER:
197600690
ADMINISTRATOR:HITZ, JADEFACILITY TYPE:
735
ADDRESS:17712 PARTHENIATELEPHONE:
(818) 349-3440
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 5DATE:
06/01/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Josh Brown- AdminstatorTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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Staff did not properly report an incident involving a client.
INVESTIGATION FINDINGS:
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On 06/01/23 Licensing Program Analysts (LPAs) Mariana Agban and Angela Paunishikina conducted an unannounced intial complaint visit for the above allegation. LPAs arrived at the facility and were granted access by staff #1 (S1), Tasha Davis. Administrator arrived shortly after and LPAs explained the reason for the visit.

During the course of the investigation, interview and record review was made. At 9:20am, LPA team conducted a physical plan tour, to ensure health and safety of the clients are protected and is in compliance with Title 22 Regulations. At 9:30am, LPA team requested copies of pertinent infomation which include, but not limited to Physician's Report, Appraisal Needs and Services Plan, Individual Program Plan (IPP), etc., relevent to the investigation. Between 9:35am-10:30am, LPAs interviewed the Administrator and three (3) staff members. LPAs also reviewed documents between 10:30am-11:00am.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
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-20230525160102
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: THERAPEUTIC LIVING CENTERS FOR THE BLIND
FACILITY NUMBER: 197600690
VISIT DATE: 06/01/2023
NARRATIVE
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Regarding the allegation, it is alleged that the facility failed to report an incident that happened on 05/13/23 to North Los Angeles Regional Center. LPAs conducted interviews with the Administrator regarding this incident. Information obtained through interviews and documentation reveal that the incident with C1 occurred on 05/13/23 and the written notification was submitted to the Regional Center at approximately 05/26/23, which based on the seriousness of the incident, it was not reported in a timely manner. In addition, during todays visit, LPAs also reviewed Regional Offices' (RO) Incident Report Files and did not observe C1's incident being submitted. Based upon the information obtained this allegation is deemed Substantiated at this time

Deficiency cited on LIC9099-D

Exit interview conducted, appeal rights discussed and copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
05/25/2023 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20230525160102

FACILITY NAME:THERAPEUTIC LIVING CENTERS FOR THE BLINDFACILITY NUMBER:
197600690
ADMINISTRATOR:HITZ, JADEFACILITY TYPE:
735
ADDRESS:17712 PARTHENIATELEPHONE:
(818) 349-3440
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 5DATE:
06/01/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Josh Brown- AdminstatorTIME COMPLETED:
01:05 PM
ALLEGATION(S):
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9
Staff did not prevent a client from sustaining multiple unexplained injuries while in care.
INVESTIGATION FINDINGS:
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On 06/01/23 Licensing Program Analysts (LPAs) Mariana Agban and Angela Paunishikina conducted an unannounced intial complaint visit for the above allegations. LPAs arrived at the facility and were granted access by staff #1 (S1), Tasha Davis. Administrator arrived shortly after and LPAs explained the reason for the visit.

During the course of the investigation, interview and record review was made. At 9:20am, LPA team conducted a physical plan tour, to ensure health and safety of the clients are protected and is in compliance with Title 22 Regulations. At 9:30am, LPA team requested copies of pertinent infomation which include, but not limited to Physician's Report, Appraisal Needs and Services Plan, Individual Program Plan (IPP), etc., relevent to the investigation. Between 9:35am-10:30am, LPAs interviewed the Administrator and three (3) staff members.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20230525160102
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: THERAPEUTIC LIVING CENTERS FOR THE BLIND
FACILITY NUMBER: 197600690
VISIT DATE: 06/01/2023
NARRATIVE
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Interview with the Administrator and three (3) staff members revealed that due to C1's medical condition, C1 wears helmet and arm braces (to prevent full arm bending and self-injury). Additionally, LPA conducted record review and obtained C1’s Behavior Support Plan (BSP) that reflect various issues that C1 needs to work on such as self-injury, tantrums, and various preventative measures to be taken by staff. LPAs were also informed that on 05/12/23, C1's Occupational Therapist, ordered a new (shorter) arm braces and it gave C1 an opportunity to self-harm which resulted in an incident that occurred on 05/13/23. C1 hit the left side of his/her head (close to the eye) few times before the facility staff was able to redirect C1. Facility staff immediately contacted the facility's nurse and were informed to replace the new (shorter) arm braces with the old ones (longer). Lastly, Administrator informed LPAs that all necessary parties were verbally notified regarding C1's incident and on 05/14/23, C1 was taken to Emergency Room by S4 for a check up.

Based on interviews and document review, during the course of the investigation this allegation is deemed Unsubstantiated at this time.

No deficiency issued.
Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20230525160102
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: THERAPEUTIC LIVING CENTERS FOR THE BLIND
FACILITY NUMBER: 197600690
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2023
Section Cited
CCR
80061(b)(1)
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Reporting requirement. Upon the occurrence, during the operation of the facility of any of the events specified... (1) report shall be made to the licensing agency within the next working day...
This requirement was not met evidenced by:
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Administrator agreed to submit an Incident report to the Regional Center, C1's family and CCLD.
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Based on interviews and doucmentation an incident occurred with C1 on 05/13/23 and was not reported in a timely manner, which poses a potential health and safety risk to the 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: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5