197601032-11-7-2024-31-AS-EMIR-DF7NY2-20250328105157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197601032
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:12:24 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
11/04/2024 and conducted by Evaluator Michael Cava

COMPLAINT CONTROL NUMBER: 31-AS-20241104150742

FACILITY NAME:	EUNICE HOME II		FACILITY NUMBER:	197601032
ADMINISTRATOR:	AGBEDE, SONNY		FACILITY TYPE:	735
ADDRESS:	17131 COURBET STREET		TELEPHONE:	(818) 831-5282
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 6	DATE:	11/07/2024
		UNANNOUNCED	TIME BEGAN:	09:17 AM
MET WITH:	Sonny Agbede, Fola Campbell		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff are not following resident's care plan
Resident has an unexplained bruise

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with staff, Fola Campbell, and advised her of the complaint. The administrators Sonny Agbede and Manager, Ana Gover were notified over the telephone. Today's investigation consisted of interviews, record review and a physical plant inspection.

Staff are not following Resident 1's (R1) care plan:
In regards to the allegation, it was reported that R1 requires a one to one care staff at all times, but they were left unattended and neglected for approximately twenty-six minutes. Interviews with both the administrator and manager confirm that R1 requires one to one supervision, and there is supervision present at all times for R1 when R1 is at the facility. R1 attends day program from 9am to 3pm daily, and is provided one to one supervision there. From 3pm to 11pm, there is one to one supervision provided by the facility. Then from 11pm-9am the following day, another one to one supervision is provided. Interviews

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20241104150742

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 II	FACILITY NUMBER: 197601032
	VISIT DATE: 11/07/2024

NARRATIVE

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with two (2) of two staff deny the allegation, adding there is one to one supervision at all times. If one staff needs to go on break, they will ask one of the other staff to cover. There is at least two to four staff, including the administrator and manager, on duty at all times. Interviews with six (6) six residents could not corroborate with the allegation. Based on the information obtained, there was insufficient evidence to prove that staff are not following R1's care plan. Therefore, the allegation is deemed Unsubstantiated at this time.

Resident has an unexplained bruise:
In regards to the allegation, it was reported that R1 has a bruise to the left side of the stomach. Interviews with the administrator, manager, and two (2) of two staff confirm that R1 has a bruise to the stomach, but it is not an unexplained injury, or due to any abuse. Both administrator, manager, and the two staff stated R1 has a history of aggressive and self injurious behavior. R1 has a tendency to pull on their skin throughout their body, causing injuries and bruises. A review of R1's records confirm that they engage in self injurious behavior, most recently to their stomach. There is also documentation that the administrator has been taking R1 to their medical appointment to treat them for the wound. According to the administrator, R1's injury is healing. Interviews with six (6) six residents could not corroborate with the allegation. Based on the information obtained, although there is documentation and admission that R1 has sustained an injury to the stomach area, their injury was caused by R1's aggressive behavior to self, and not unexplained. Therefore, the allegation of R1 has an unexplained bruise is deemed Unsubstantiated at this time.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC9099 (FAS) - (06/04)

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