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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604906
Report Date: 08/10/2022
Date Signed: 08/10/2022 04:13:17 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
08/10/2022 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20220810091711
FACILITY NAME:DORIS' RESIDENTIAL CARE FACILITYFACILITY NUMBER:
197604906
ADMINISTRATOR:DORIS DUONGFACILITY TYPE:
735
ADDRESS:8012 NEWCASTLE AVENUETELEPHONE:
(818) 774-9706
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:4CENSUS: 3DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Doris DuongTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Lack of care and supervision
Client suffered multiple injuries from physical abuse as a result of lack of care and supervision
INVESTIGATION FINDINGS:
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At 1:00 p.m. on 08/102022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint investigation. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. During the physical plant inspection, no immediate health and safety concerns were observed.

Lack of care and supervision
Regarding the allegation above, it was alleged the facility did not provide proper care and supervision for Client #1 (C1). LPA Reed conducted interviews of Staff #1 (S1), facility administrator (S2), a family member (F1), and C1 on 08/10/2022 from 1:30 p.m. to 2:45 p.m. LPA conducted a records review at 1:55 p.m. From interviews, S1 and S2 provided care and supervision from approximately 2:00 p.m. on 08/05/2022 to approximately 4:00 p.m. on 08/06/2022. F1 picked up C1 from the facility at approximately 4:00 p.m. on 08/06/2022 for dinner and a haircut. C1 returned to the facility at approximately 8:00 p.m. on 08/06/2022. S1 provided care and supervision to C1 from approximately 8:00 p.m. on 08/06/2022 to 8:20 a.m. on 08/08/2022.
Unsubstantiated
Estimated Days of Completion: 1
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
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-20220810091711
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: DORIS' RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 197604906
VISIT DATE: 08/10/2022
NARRATIVE
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 Based on interviews and records review, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Client suffered multiple injuries from physical abuse as a result of lack of care and supervision
Regarding the allegation above, it was alleged C1 sustained cuts on their neck as a result of a lack of facility care and supervision. From interviews, S1, F1, and C1 confirmed that F1 shaved C1’s neck on 08/06/2022. C1 confirmed the marks are not painful, though C1 is not sure where the marks came from. Based on interviews and observations, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Copy of report issued.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2