197605522-10-12-2022-29-AS-JAPL-CKK2JM-20221025172631

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 10/12/2022
Date Signed: 10/12/2022 11:09:58 AM

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
03/01/2022 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20220301110139

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: 4	DATE:	10/12/2022
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Yuliya Asatryan-Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not inform responsible party of resident's change in condition
Facility did not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Elsie Campos arrived unannounced to conduct a subsequent complaint visit to deliver the findings for the above allegations. The LPA met with Yuliya Asatryan and explained the reason for the visit.

It was alleged that the facility failed to inform the responsible party (RP) of Resident #1 (R1s) change in medical condition. Document review and interviews revealed that R1 is conserved by the court and the complainant is not R1’s RP. The LPA received documentation confirming that on 2/20/2022, R1’s conservator was informed of an unusual mark discovered on R1s wrist. Staff interviews further confirmed that R1s conservator was informed of R1s change in condition. The complaintant further alleged that they were not notified of R1 obtaining sores on their body, however medical record review did not reveal any sores discovered on R1s body. Staff are required to inform R1s court appointed conservator of any changes, the Admistrator provided documentation confimring that R1s conservator was informed of the changes.

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: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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 29-AS-20220301110139

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: 10/12/2022

NARRATIVE

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Based on the information obtained, there is insufficient evidence to support the claim, staff did not notify responsible party of residents change in condition. This allegation is deemed Unsubstantiated at this time.

Regarding the allegation: Facility did not safeguard resident's personal belongings

It was alleged that when R1 was admitted to the hospital the complainant went to the facility to gather R1s belongings and observed that some belongings were missing. Information obtained revealed that R1s husband had been given a diamond ring that belonged to R1 when R1s husband was still R1s responsible party. Staff interviews confirmed that R1s belongings had been handed over to R1s daughter and husband. Additionally, when R1 moved out of the facility staff documented R1s belongings to ensure that they had a record of what was given back to the family. Based on the information obtained during the course of the investigation, there is insufficient evidence to support the claim that staff failed to safeguard resident's personal belongings. This allegation is deemed Unsubstantiated at this time.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC9099 (FAS) - (06/04)

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