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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197601032
Report Date: 06/24/2024
Date Signed: 06/24/2024 05:12:13 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
06/18/2024 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20240618154559
FACILITY NAME:EUNICE HOME IIFACILITY NUMBER:
197601032
ADMINISTRATOR:AGBEDE, SONNYFACILITY TYPE:
735
ADDRESS:17131 COURBET STREETTELEPHONE:
(818) 831-5282
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 6DATE:
06/24/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Sonny Agbede (Administrator)TIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Staff did not comply with reporting requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Evelin Rios arrived at the facility in response to the above mentioned allegation. LPA was greeted by facility staff. Staff called the administrator and informed them LPA was at the facility. Administrator, Sonny Agbebe met LPA shortly after. LPA explained the purpose of the visit. Entrance interview conducted.

LPA conducted a physical plant tour of the facility to ensure the health and safety of the clients in care. From approximately 12:00 p.m. to 3:10 p.m. LPA interviewed the administrator, four (4) staff and six (6) clients present at the time of visit. From 1:30 p.m. to 2:00 p.m, LPA reviewed 06/07/2024, Special Incident Report (SIR) sent to Community Care Licensing (CCL) from the facility.

Allegation: Staff did not comply with reporting requirements. It is alleged a staff reported to the administrator alleged abuse and administrator did not report the alleged abuse to the appropriate agencies. (Continued to LIC9099-C)

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
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 4
Control Number 31-AS-20240618154559
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: EUNICE HOME II
FACILITY NUMBER: 197601032
VISIT DATE: 06/24/2024
NARRATIVE
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Review of SIR revealed staff #1(S1) was allegedly told by another Staff #2(S2) that they had witnessed a third staff, staff #3(S3) slap client#1(C1). LPA's interview with S1 confirms the individual was made aware of alleged abuse sometime in May 2024. LPA's interview with administrator revealed after they were made aware in June 6, 20204 they sent SIR to North Los Angeles County Regional Center (NLACRC) and CCL but they did not complete the Report of Suspected Dependent Adult/Elder Abuse SOC341 and send it to appropriate agencies or to notify appropriate agencies such as law enforcement and Long Term Care Ombudsman of alleged abuse. According to the administrator they conducted their own investigation to determine if alleged abuse had occurred and decided not to send one because they felt their was not enough evidence to corroborate abuse as S2 had denied witnessing abuse and no date or time provided for alleged abuse. According to administrator S1 had told them they assumed the administrator was told of alleged abuse which was not the case. According to administrator S1 failed to report information to administrator via Special Incident Report which caused an overall delay in reported. Although administrator submitted Special Incident Report (SIR) to CCL and NLACRC they failed to complete SOC341, this form documents the information given by the reporting party on the suspected incident of abuse or neglect of an elder or dependent adult. Based on this information the allegation is deemed Substantiated at this time.


Deficiency Cited (refer to LIC9099). Appeal rights provided. Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20240618154559
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: EUNICE HOME II
FACILITY NUMBER: 197601032
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
CCR
80061(d)
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(d) Any suspected physical abuse that does not result in serious bodily injury of ...dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement is not met as evidenced by:
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Administrator agrees submit soc341 to all appropraite agencies and a copy to LPA by POC due date 07/05/2024.
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Based on an interview with the Administrator and record review, the licensee failed to report the alleged incident of abuse to appropraite agencies regarding C1, which posses a potential risk to the personal rights of 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: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4