197601489-5-30-2024-29-AS-KHEN-D5STV9-20240531150334

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197601489
Report Date: 05/30/2024
Date Signed: 05/30/2024 02:09:28 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20220426135424

FACILITY NAME:	CARRIE'S BOARD AND CARE		FACILITY NUMBER:	197601489
ADMINISTRATOR:	CARRIE ACOSTA		FACILITY TYPE:	740
ADDRESS:	8430 COLBATH AVENUE		TELEPHONE:	(818) 893-7619
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 4	DATE:	05/30/2024
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Carrie Acosta, Licensee		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff failed to complete pre-admission appraisals prior to move in.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit at the facility today to deliver findings. At 1:18 p.m., the LPA met with the Licensee and explained the reason for the visit.

During the initial visit on 5/02/2022, between 10:30 a.m. and 2:00 p.m., LPA Peraldi conducted a facility tour and reviewed records and obtained copies of pertinent documents. The LPA also conducted interviews with the Licensee, three (3) residents and two (2) staff.

Continued on LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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 5

Control Number 29-AS-20220426135424

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIE'S BOARD AND CARE	FACILITY NUMBER: 197601489
	VISIT DATE: 05/30/2024

NARRATIVE

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Regarding the allegation: Staff failed to complete pre-admission appraisals prior to move in. On 04/26/2022, the Department received a complaint alleging that the Licensee did not complete a pre-admission appraisal for Resident #1 (R1) prior to move in. During the initial visit, the LPA reviewed R1’s file and received a copy of R1’s records and documents. R1’s records did not include a pre-admission appraisal. Based on record review, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit (See 9099-D).

Exit interview conducted. A copy of the report and appeal rights was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 29-AS-20220426135424

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIE'S BOARD AND CARE	FACILITY NUMBER: 197601489
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/30/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/30/2024 Section Cited CCR 87457(c)	1 2 3 4 5 6 7	87457 (c) Pre-Admission Appraisal - General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed...This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The Licensee stated that she will submit a statement of understanding about the regulation by due date.
	8 9 10 11 12 13 14	Based on record review, the licensee did not comply with the section cited above as R1 did not have pre-admission appraisals, which posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2022 and conducted by Evaluator Emily Peraldi

COMPLAINT CONTROL NUMBER: 29-AS-20220426135424

FACILITY NAME:	CARRIE'S BOARD AND CARE		FACILITY NUMBER:	197601489
ADMINISTRATOR:	CARRIE ACOSTA		FACILITY TYPE:	740
ADDRESS:	8430 COLBATH AVENUE		TELEPHONE:	(818) 893-7619
CITY:	PANORAMA CITY	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 4	DATE:	05/30/2024
		UNANNOUNCED	TIME BEGAN:	01:18 PM
MET WITH:	Carrie Acosta, Licensee		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff not giving resident personal belongings.
Staff not providing adequate food service.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20220426135424

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARRIE'S BOARD AND CARE	FACILITY NUMBER: 197601489
	VISIT DATE: 05/30/2024

NARRATIVE

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Regarding the allegation: Staff not giving resident personal belongings. On 04/26/2022, the Department received a complaint alleging that the Licensee withheld Resident #1 (R1) personal belongings while R1 was moving out. The complainant stated that the Licensee went through R1’s belongings and refused to give it back. During the initial visit, the Licensee stated that R1 took all of R1’s belongings during move out. The Licensee said that R1 was residing at the facility for one (1) month and had a small inventory of personal belongings. The Licensee provided the LPA with a document dated on 03/11/2022 that had a list of R1’s personal belongings signed by the Licensee and R1. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Staff not providing adequate food service. On 04/26/2022, the Department received a complaint alleging facility food being horrible. During the initial visit, majority of resident interviews did not have issues with quality of food or food service. During the visit, the LPA observed sufficient amount of vegetables, meat, and fruit. The LPA had a conversation with the Licensee about grocery shopping and updating the facility menu. The information obtained during the investigation did not include evidence sufficient to corroborate the allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC9099 (FAS) - (06/04)

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