197605522-1-3-2022-29-AS-JAPL-CBMUEA-20220214143047

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197605522
Report Date: 01/03/2022
Date Signed: 01/03/2022 05:41:42 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
12/30/2021 and conducted by Evaluator Elsie Campos

COMPLAINT CONTROL NUMBER: 29-AS-20211230120202

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:	01/03/2022
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Yuliya Asatryan and Francisca Recede		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is retaliating against resident for filing a complaint

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Ashley Smith and Elsie Campos arrived unannounced for an initial 10-day visit. The LPAs met with Yuliya Asatryan and Francisca Recede and explained the reason for the visit.

During today’s visit, the LPAs conducted a medication audit at 11:30 a.m., interviewed Resident #1 (R1) at 11:40 a.m., completed a plant tour at 11:50 a.m., interviewed staff at 12:00 p.m., and interviewed the responsible parties of four (4) residents at 12:45 p.m., 2:33 p.m., 2:49 p.m., 3:08 p.m., and 3:44 p.m. In addition, the LPAs reviewed pertinent documents.

Allegedly the facility is retaliating against R1 due to R1’s family member allegedly filing a complaint against the facility. It is alleged that R1 was issued an eviction notice. Interviews with staff and R1’s family members regarding R1, provided inconsistent statements as to what transpired.

Cont. on 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: 01/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022

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 29-AS-20211230120202

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: 01/03/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The Administrator admitted that they requested that R1 be moved to a different facility as it appeared that R1’s family was unhappy with the care. A facility file review revealed that there have been prior incidents between R1’s family member and facility staff concerning R1’s care. Information obtained from the interview with the Administrator confirmed that the Administrator was aware that R1 cannot be evicted due to the actions of a family member. Interview with R1’s conservator revealed that the conservator is very happy with R1’s care and they will not be moving R1 to a different facility. An interview with R1 further revealed that they are happy and well taken care of. R1 did not communicate any negative remarks regarding the care they received. Interviews and records review confirmed that the facility did not issue an official eviction notice.

Interviews with resident family members and conservators revealed that they believed their loved ones were receiving appropriate care in this facility. Interviews stated that they felt comfortable with their loved ones residing in the facility. They denied claims of any suspicion of abuse or neglect. Many of the residents have resided at this location for several years and have had no complaints regarding care or treatment of their loved ones.

Based on the investigation there is insufficient evidence to support the claims that the facility is retaliating against the resident. 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: 01/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2