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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 10/19/2021
Date Signed: 10/19/2021 02:53:53 PM



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
09/17/2021 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 29-AS-20210917141855
FACILITY NAME:A HEAVENLY HAVEN, INC.FACILITY NUMBER:
197605522
ADMINISTRATOR:FRANCISCA M. RECEDEFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 713-0447
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
10/19/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Francisca Recede, AdministratorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff refused to call resident's doctor
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit to deliver the investigation finding for the above allegations. The LPA met with administrator Francisca Recede at 12:35 p.m. and explained the reason for the visit.

On 09/22/2021, LPA Walker conducted an initial complaint visit. the LPA conducted a physical plant tour at 10:05 a.m. From 11:28 a.m. until 11:48 a.m., the LPA conducted interviews with family members of residents living at the facility. From 11:50 a.m. until 12:30 p.m., the LPA reviewed and obtained copies of documents pertinent to the investigation.
During today’s visit, the LPA conducted a physical plant tour at 1:30 p.m. to ensure there are no health and safety hazards.

Continue on LIC 9099C..
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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-20210917141855
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: 10/19/2021
NARRATIVE
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Regarding the allegation, ‘Staff refused to call resident's doctor,’ the complainant’s concern is that staff was asked to call R1’s doctor, and staff refused to call. The complainant alleged that staff’s reason for not calling was that R1 is always saying they are in pain.
During the investigation, the LPA attempted to contact R1’s doctor multiple times with no success. The LPA also conducted interviews with the administrator, and staff. Interviews revealed that staff admitted they did not call R1’s doctor as they did not feel R1 needed medical attention. Staff claimed R1 was always screaming. However, as staff failed to seek medical attention to assess if R1 was in pain, staff were unable to determine by way of calling 911.
Based on interviews with the administrator and staff, there is sufficient evidence to support the allegation ‘Staff refused to call resident's doctor.’ Therefore, this allegation is deemed Substantiated at this time.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code.

Exit interview conducted, a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 29-AS-20210917141855
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2021
Section Cited
CCR
87465(g)
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87465(g)Incidental Medical and Dental Care Services. The licensee shall immediately telephone 9-1-1 if.. circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis..
This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:
1.Submit a plan of action as to what steps will be taken to ensure compliance.
2.Submit training log for staff reviewal of section 87465(g) to CCL by 10/26/2021.
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Based on interviews, the licensee failed to ensure facility staff called 911 immediately after nor the PCP to assess whether R1 was indeed in pain, which posed an immediate health and safety risk to resident in care.
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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
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
09/17/2021 and conducted by Evaluator Salia Walker
COMPLAINT CONTROL NUMBER: 29-AS-20210917141855

FACILITY NAME:A HEAVENLY HAVEN, INC.FACILITY NUMBER:
197605522
ADMINISTRATOR:FRANCISCA M. RECEDEFACILITY TYPE:
740
ADDRESS:5504 FALLBROOK AVENUETELEPHONE:
(818) 713-0447
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:6CENSUS: 4DATE:
10/19/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Francisca Recede, AdministratorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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9
Staff is not following resident's wheelchair care plan

Facility has pests
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salia Walker arrived unannounced for a subsequent complaint visit to deliver the investigation finding for the above allegations. The LPA met with administrator Francisca Recede at 12:35 p.m. and explained the reason for the visit.

On 09/22/2021, LPA Walker conducted an initial complaint visit. the LPA conducted a physical plant tour at 10:05 a.m. From 11:28 a.m. until 11:48 a.m., the LPA conducted interviews with family members of residents living at the facility. From 11:50 a.m. until 12:30 p.m., the LPA reviewed and obtained copies of documents pertinent to the investigation.
During today’s visit, the LPA conducted a physical plant tour at 1:30 p.m. to ensure there are no health and safety hazards.

Continue on LIC 9099C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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-20210917141855
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: 10/19/2021
NARRATIVE
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Regarding the allegation, ‘Staff is not following resident's wheelchair care plan,’ it was alleged that Resident #1’s (R1’s) wheelchair footrest is being taken off, and staff are not supposed to do so because it causes pain to R1.
During the physical plant tour, the LPA observed that R1’s wheelchair footrest was on R1’s wheelchair and had not been removed. The LPA also conducted interviews with the administrator, and staff. Interviews revealed that R1’s footrest is removed during mealtimes to provide additional comfort.
Based on record review, the LPA confirmed that there is no wheelchair care plan assigned to R1. Based on LPA’s observation, interviews with administrator, and staff confirmed that the footrest is placed back on R1’s wheelchair after mealtimes. There is insufficient evidence to support the allegation ‘Staff is not following resident's wheelchair care plan.’ therefore this allegation is deemed Unsubstantiated at this time.

Regarding the allegation, ‘Facility has pests,’ the complainant’s concern is that the facility has a lot of spider webs, and a black widow spider was observed outside the facility’s windows.
During the physical plant tour spider webs were observed, but no spiders. Although there are some spider webs along the outside of the facility, when the LPA checked all the window screenings they were properly fitted and sealed. The LPA inspected the window screenings, and did not find them to have any access for insects to enter.
Based on LPA’s observation, there is insufficient evidence to support the allegation ‘Facility has pests.’ Therefore, this allegation is deemed Unsubstantiated at this time.

Exit interview conducted, a copy of the report was provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5