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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606176
Report Date: 05/11/2022
Date Signed: 05/11/2022 02:15:13 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
05/05/2022 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20220505132306
FACILITY NAME:KATHYANN HOME INC.FACILITY NUMBER:
197606176
ADMINISTRATOR:LA SEAN JAMESFACILITY TYPE:
735
ADDRESS:11906 KATHYANN STREETTELEPHONE:
(818) 201-7225
CITY:LAKEVIEW TERRACESTATE: CAZIP CODE:
91342
CAPACITY:4CENSUS: 4DATE:
05/11/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Louise McMillonTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff failed to seek medical attention for resident in a timely manner
Staff yell at client
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced complaint visit to investigate the allegations above. LPA met with facility staff and explained the reason for this visit. LPA spoke with the administrator by telephone and explained the reason for this visit.
LPA conducted a physical plant tour to ensure no immediate health and safety issues from 10:15-10:25am. No immediate health and safety issues were observed.
Staff failed to seek medical attention for resident in a timely manner
It is alleged that client #1 (C1) had an issue with their hands and facility failed to seek medical attention in a timely manner. LPA conducted interviews with C1 and facility staff from 10:25-11am. LPA also reviewed C1's facility file and obtained copies of pertinent information from 11-12pm. Information obtained through interviews and documentation found that C1 has had an issue with their hands dating back to October 2021 and that the facility has taken C1 to see their physician on multiple occasions. LPA received documentation that shows C1 has been seen by their personal physician in October 2021, December 2021, February 2022, and several times in March 2022.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
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-20220505132306
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: KATHYANN HOME INC.
FACILITY NUMBER: 197606176
VISIT DATE: 05/11/2022
NARRATIVE
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Based on the information obtained through interviews and documentation this allegation is deemed Unsubstantiated at this time.

Staff yell at client
It is alleged that facility staff yell at C1. LPA conducted interviews with C1, other clients, and facility staff from 10:25-11am regarding this allegation. Information obtained through interviews reveal that staff do not yell at C1 according to C1 and clients in the facility. Based on information obtained through interviews this allegation is deemed Unsubstantiated at this time. Exit Interview conducted.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2