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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606909
Report Date: 02/06/2025
Date Signed: 02/06/2025 03:38:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
02/05/2025 and conducted by Evaluator Perchui Khurshudyan
COMPLAINT CONTROL NUMBER: 31-AS-20250205120913
FACILITY NAME:PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIAFACILITY NUMBER:
197606909
ADMINISTRATOR:ANGELICA SERRANOFACILITY TYPE:
735
ADDRESS:22005 PARTHENIA AVENUETELEPHONE:
(747) 242-1038
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY:5CENSUS: 4DATE:
02/06/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jacob Pascasio- ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not comply with the client's Admission Agreement
INVESTIGATION FINDINGS:
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On 2/6/2025 at 1:00pm, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced, initial 10-day visit to investigate the above allegation. Upon arrival, LPA met with the facility Manager -Jacob Pascasio, introduced herself by showing her badge, and explained the reason for the visit.

To investigate the complaint, LPA requested copies of client and staff rosters, clients’ files and obtained copies of pertinent documents which include, but not limited to Admission Agreement, Physician Reports, Individual Program Plan (IPP), Approved Program design for the facility.
At 1:45pm LPA obtained copies of staff / DSP work schedules and shifts.
LPA conducted a physical plant tour at approximately 2:30pm and observed that the house is generally clean and organized.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025
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 3
Control Number 31-AS-20250205120913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA
FACILITY NUMBER: 197606909
VISIT DATE: 02/06/2025
NARRATIVE
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It was reported that on 1/16/2025, credible witness from North LA County Regional Center (NLACRC) conducted an unannounced visit at People Create Success (PCS) Parthenia home and observed PCS Parthenia facility was missing 32 hours of DSP coverage on the following weekends: 12/15/2024, 12/21/2024-12/22/2024,12/28/2024-12/29/2024, 1/4/2025-1/5/2025, 1/11/2025-1/12/2025, and 1/18/2025-1/19/2025, 28 hours of DSP coverage for the following PM shifts (3pm-11pm): 12/16/2024-12/20/2024,12/23/2024, 12/25/2024,12/27/2024,12/30/2024-1/2/2025,1/6/2025-1/10/2025, 1/13/2025-1/17/2025, 1/20/2025-1/24/2025, and 20 hours of DSP coverage missing on 12/24/2024 and 12/26/2024. This resulted failure of following approved program design for the health and safety of all clients and violation of the terms of the clients’ Admission Agreement.

Based on interviews and documentation review, there is enough evidence of confirming the allegation, therefore, this allegation is deemed to be Substantiated.

Deficiencies issued on LIC9099-D, Appeal rights provided.

Exit interview conducted and copy of this report delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250205120913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PEOPLE CREATING SUCCESS, INC. PCS-PARTHENIA
FACILITY NUMBER: 197606909
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2025
Section Cited
CCR
80065(a)
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Personnel Requirements(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement is not met as evidenced by:
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Licensee/Administrator will ensure
there are three core staff on shift, every shift,
for the entire shift in addition to 1:1 staffing when all four residents are home to ensure the health and safety of the consumers residing in the home. Licensee will submit LIC500 to LPA by POC due date.
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Based on observation, records review, and interviews, the licensee did not comply with the section cited above in ensuring to have DSP core staffing on shifts as per the approved program
design coverage for all set shifts,
which poses potential health, safety or personal rights risk to persons in care.
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Type B
03/04/2025
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision(a)The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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Licensee/Administrator, will submit the facility’s 24- hour staffing schedule / LIC500, including the 1:1 staffing hours demonstrating the required hours are being met to LPA by POC due date.
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Based on observation, records review, and interviews, the licensee did not comply with the section cited above by not having sufficient staff DSP, which poses potential health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC9099 (FAS) - (06/04)
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