197606744-1-3-2023-29-AS-DPEA-CN6SPL-20230117130315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197606744
Report Date: 01/03/2023
Date Signed: 01/03/2023 02:05:25 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
08/26/2020 and conducted by Evaluator Brian Balisi

COMPLAINT CONTROL NUMBER: 29-AS-20200826090127

FACILITY NAME:	ETTA ISRAEL CENTER ADULT RESIDENTIAL #3		FACILITY NUMBER:	197606744
ADMINISTRATOR:	AARON KHODORKOVSKY		FACILITY TYPE:	735
ADDRESS:	12655 EMELITA AVENUE		TELEPHONE:	(818) 358-3008
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 6	DATE:	01/03/2023
		UNANNOUNCED	TIME BEGAN:	12:58 PM
MET WITH:	Giovanna Molina		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff locked resident in the room

Staff donated residents belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced subsequent complaint visit to deliver findings for the allegations listed above. Upon arrival LPA met with Giovanna Molina and explained the reason for the visit.
On 8/28/2020, LPA conducted virtual visit with Administrator Hiedi Scofield , and requested documents pertinent to the investigation. LPA is unable to contact Reporting party at this time.

On 12/28/2022, LPA conducted subsequent visit, conducted physical plant, interviewed staff, residents and reviewed and obtained additional documents relevant to the investigation. LPA also conducted collateral visit at Etta Israel Adult Residential #2 ( 198600051) to interview Resident 1 (R1).

At approximately 1pm, LPA conducted physical plant, interviewed staff and reviewed and obtained pertinent documents relevant to the investigation.
Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

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-20200826090127

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: ETTA ISRAEL CENTER ADULT RESIDENTIAL #3	FACILITY NUMBER: 197606744
	VISIT DATE: 01/03/2023

NARRATIVE

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Continued from 9099

It was alleged that Staff 1 (S1) locked R1 in their room. LPAs records review revealed that R1 has only resided at Etta Israel Adult Residential #2 and S1 has only been employed at this facility. LPAs interview with R1 and R1's responsible party revealed that R1 has never had any interaction with S1 and they do not recognize the name of S1. LPAs interview with staff and back up Administrator further revealed S1 has only worked at this facility and R1 has only resided at Etta Israel #2. LPA interview with (4) residents at this facility revealed that each remember S1 working at this facility and each resident also confirmed R1 has never resided at this facility. Interview with the residents further revealed they each have never witnessed S1 lock any resident in their rooms. Based on information gathered during this and previous visits, the department does not have sufficient evidence to prove this allegation occurred. Therefore the allegation that S1 locked R1 in their room has been deemed UNSUBSTANTIATED at this time.

It was alleged S1 donated Resident 2 (R2)'s belongings with specifics on R2's arts and crafts. LPA interview with R2 revealed they have never had any concerns about missing any of their arts and crafts materials. During interview with R2, LPA observed a number of arts and crafts materials on R2s shelf in their private bedroom. Interview with R2 further revealed that R2 is the only one ever allowed to touch their arts and crafts materials. Staff only provide R2 with assistance with their arts and crafts upon request. LPA's interview with other residents in care revealed that each have never witnessed S1 donate R2's belongings or any of their belongings. Interviews with the residents further revealed that each have not expressed any immediate or potential concerns of any staff donating their personal belongings. LPA interview with Staff and back-up Administrator revealed they each have never donated any of R2's personal belongings or arts and crafts materials. Interview with staff also revealed that each have never witnessed other staff donate R2's or any other residents personal belongings. Based on information gathered during this and previous visits, the department does not have sufficient evidence to prove this allegation occurred. Therefore the allegation that S1 donated R2's personal belongings has been deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Reported issued and sent via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023

LIC9099 (FAS) - (06/04)

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