197605522-4-9-2022-29-AS-JAPL-CDDR5M-20220411124321

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 04/09/2022
Date Signed: 04/09/2022 04:39:47 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. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/27/2021 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20211227114555

FACILITY NAME:	A HEAVENLY HAVEN, INC.		FACILITY NUMBER:	197605522
ADMINISTRATOR:	FRANCISCA M. RECEDE		FACILITY TYPE:	740
ADDRESS:	5504 FALLBROOK AVENUE		TELEPHONE:	(818) 713-0447
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 3	DATE:	04/09/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Yuliya Asatryan and Aguilon ‘Auggie’ Florencio		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility staff are not following COVID-19 masking guidelines.
Facility staff inappropriately handled resident in care.
Facility staff interfered with resident's right to have a visitor.
Facility staff yelled in front of residents.
A facility chair was not clean (soiled with urine and or feces).

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Elsie Campos and Ashley Smith arrived to the facility unannounced for a subsequent complaint visit. The LPAs initially met with staff, whom contacted Administrator Yuliya Asatryan regarding the visit. The LPAs thereafter met with Administrator Yuliya Asatryan and explained the reason for the visit.

During the initial visit conducted on 12/29/2021, the LPA’s conducted a tour at 10:56 a.m., interviewed staff at 11:12 a.m., interviewed the administrator at 11:41 a.m., and obtained documents. Today, the LPAs conducted a tour at 10:40 a.m., reviewed documents at 10:50 a.m., and interviewed staff at 11:30 a.m., 11:55 a.m., 12:10 p.m., and 12:45 p.m.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022

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 4

Control Number 29-AS-20211227114555

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A HEAVENLY HAVEN, INC.	FACILITY NUMBER: 197605522
	VISIT DATE: 04/09/2022

NARRATIVE

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Regarding the allegation: Facility staff are not following COVID-19 masking guidelines.
It was alleged that the facility staff were not wearing masks appropriately. Information obtained revealed the Administrator was at the facility on 12/26/21 where it was alleged that the Administrator was not wearing their mask properly. Interviews revealed that the Administrator was observed putting down their mask when consuming water. Per interviews, at no time were masks not being worn; however, the Administrator did admit to pulling down their mask in order to drink water. Staff interviews revealed that all staff were wearing masks and also confirmed that the only time the administrator would pull down their mask was at the time of consuming water. Based on the information obtained, there is insufficient evidence to support the claim, that the facility staff are not following COVID-19 masking guidelines. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility staff inappropriately handled resident in care.
It was alleged that due to R1’s yelling, R1 was placed in their room. The complainant believed that the staff were unable to manage R1’s behaviors and implemented punitive measures by placing R1 in the room. It was also alleged that R1 was put to bed too early and that the bedtime was inappropriate. Staff interviews revealed that after dinner, R1 becomes tired and will oftentimes exhibit behaviors of yelling. Staff stated that they would not immediately place R1 in the room but claimed that R1 would yell that they were tired. Staff stated that they always attempted to get to the root of R1’s behavior and did not place R1 in the room as a punishment but would listen to R1 when R1 said they were tired. Staff claimed that they were following R1’s wishes to lay down when R1 made claims of being tired. Otherwise, staff stated that R1 would fall asleep at the dinner table or armchair, which could also be interpreted as inappropriate. Staff noted that R1 finishes dinner around 6:00 p.m. and would become tired soon after. Staff stated that as soon as R1 is placed in bed, R1 will stop yelling and R1 will go to sleep. Staff stated that R1’s yelling is common behavior for R1 but would often ask R1 about their needs and the root cause of the behavior. Staff noted that the residents have bed times based on their individual preferences and needs. Based on the information obtained, there is insufficient evidence to support the claim that facility staff inappropriately handled resident in care. This allegation is deemed Unsubstantiated at this time.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20211227114555

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A HEAVENLY HAVEN, INC.	FACILITY NUMBER: 197605522
	VISIT DATE: 04/09/2022

NARRATIVE

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Regarding the allegation: Facility staff interfered with resident's right to have a visitor.
It was alleged that the facility impeded on R1’s rights to visitation. Interviews revealed that on approximately 12/26/2021, R1 was asleep when a visitor came to see R1. It was later revealed that R1’s visitor was screened and allowed into the facility and R1’s visitor was informed that R1 was asleep Staff then noted that they were going to bring R1 out to a common space. Interviews revealed that oftentimes, R1 would have visitors in common spaces in the facility. Staff interviews revealed that they had not made claims to R1 or to R1’s visitors that they were unable to have visits in R1’s room or other areas in the facility yet had a designated visitor’s area due to COVID-19. The Administrator confirmed that at that time, they had a designated visitation area per their Mitigation Plan. During this time, R1 was brought out to the common space and R1 and R1’s visitor sat in the front living room. Inconsistent statements were shared regarding interactions that R1’s visitors have had with staff during visits. Staff have noted that if R1 is with a visitor in a common space, staff may have to enter the space for a facility related reason. However, staff claim that they will not intentionally interrupt R1’s visit. Based on the information obtained, there is insufficient evidence to support the claim that facility staff interfered with resident's right to have a visitor. R1’s visitor was allowed into the facility on 12/26/2021 and R1 was able to meet with their visitor. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility staff yelled in front of residents.
It was alleged that the facility staff yelled in front of the residents. Information obtained from interviews revealed that on 12/26/2021, R1 had a visitor come to the facility. Staff claimed that R1’s visitor came into the facility visibly upset and upon meeting the Administrator, the Administrator tried to de-escalate the situation. Inconsistent statements were received regarding the interaction between R1’s visitor and the Administrator. Whereas it was alleged that the Administrator was yelling, witnesses to the incident made claims that R1’s visitor was yelling and that the Administrator was firm in their delivery in responding to R1’s visitor. Interviews confirmed that at the time of the incident there was one other resident sitting in an adjacent living room and witnessed the interactions. Whereas they may have heard yelling, staff confirmed that the yelling was coming from R1’s visitor and not the Administrator. Based on the information obtained, whereas the Administrator admitted to setting firm boundaries with R1’s visitor and was firm in their delivery, there is insufficient evidence to support the claim, that the facility staff yelled in front of residents. This allegation is deemed Unsubstantiated at this time.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20211227114555

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: A HEAVENLY HAVEN, INC.	FACILITY NUMBER: 197605522
	VISIT DATE: 04/09/2022

NARRATIVE

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Regarding the allegation: A facility chair was not clean (soiled with urine and or feces).
It was alleged that the facility had a facility chair that was soiled with urine and or feces. During the initial visit, the LPA’s conducted a physical plant tour and visually inspected all the chairs at the facility which exhibited normal signs of wear and tear. The LPA’s confirmed that no chairs in the facility had signs of being soiled with urine or feces. During today’s visit, chairs were again inspected and were observed to be clean. Per interviews, at no time was there a chair in the facility that exhibited signs of being soiled. Based on the information obtained, there is insufficient evidence to support the claim, that a facility chair was not clean or that a chair was soiled with urine and or feces. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted and a copy of the report was emailed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2022

LIC9099 (FAS) - (06/04)

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