197607284-2-14-2022-31-AS-NMAN-CGB2BH-20220713171509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607284
Report Date: 02/04/2022
Date Signed: 02/14/2022 11:20:16 AM

Substantiated

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
01/19/2022 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220119095409

FACILITY NAME:	LIFESTYLE HOME CARE FOR SENIORS		FACILITY NUMBER:	197607284
ADMINISTRATOR:	BIENVENIDA B. GOUDEAUX		FACILITY TYPE:	740
ADDRESS:	11734 DORAL AVENUE		TELEPHONE:	(818) 368-5108
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91326
CAPACITY:	4	CENSUS: 0	DATE:	02/04/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Bienvenida Goudeaux, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility smoke detectors are in disrepair

INVESTIGATION FINDINGS:

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Facility smoke detectors are in disrepair

Licensing program Analyst (LPA) Tihesha Smith conducted unannounced complaint visit to the facility. LPA met the Administrator and explained the purpose of this visit.

It was alleged that on August 10, 2021 and on January 05, 2022 the smoke detectors are beeping and malfunctioning.

During initial visit conducted on 01/24/2022 upon entry to the facility at 10:40am, LPA Smith observed the handyman working at the facility. LPA Smith inspected the facility at 11:30am. The facility is a one-story home with 4 private bedrooms and 2 baths. There were 13 smoke detectors and all of them were hard wired throughout the facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

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 4

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
01/19/2022 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220119095409

FACILITY NAME:	LIFESTYLE HOME CARE FOR SENIORS		FACILITY NUMBER:	197607284
ADMINISTRATOR:	BIENVENIDA B. GOUDEAUX		FACILITY TYPE:	740
ADDRESS:	11734 DORAL AVENUE		TELEPHONE:	(818) 368-5108
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91326
CAPACITY:	4	CENSUS: 0	DATE:	02/04/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Bienvenida Goudeaux, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Smoke detector in common area is missing

INVESTIGATION FINDINGS:

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Licensing program Analyst (LPA) Tihesha Smith conducted unannounced complaint visit to the facility. LPA met the Administrator and explained the purpose of this visit.

It was alleged that there are no smoke detectors the common area.

During initial visit on 01/24/2022 at 11:30am, LPA Smith inspected the facility and observed that there is no need to have separate smoke detector in the common area. LPA observed a smoke detector within the same space adjacent to common area.
Based on in section and observation, there is no sufficient information to verify the allegation. Therefore, this allegation is UNSUBSTANTIATED at this time.
Exit interview was conducted and a copy of report was issued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 31-AS-20220119095409

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: LIFESTYLE HOME CARE FOR SENIORS	FACILITY NUMBER: 197607284
	VISIT DATE: 02/04/2022

NARRATIVE

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(Cont. from 9099)

On visual inspection, the smoke detectors were all on and LPA observed only the green light lit with no red beeping indicator. The administrator also presented additional newly purchased detectors still in packaging for backup. The Administrator tested the smoke detectors and all of them were operating properly.
On 01/24/2022 at 12:30pm, LPA Smith spoke with the Administrator, who verified that the facility smoke detectors were malfunctioning and the handyman present at the facility was assisting the Administrator to fix the smoke detectors.
The information revealed during this investigation verifies the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted, and a copy of report
emailed.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 31-AS-20220119095409

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: LIFESTYLE HOME CARE FOR SENIORS	FACILITY NUMBER: 197607284
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/04/2022 Section Cited CCR 87203	1 2 3 4 5 6 7	Type A. 87203 Fire Safety; All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: The Licensee did not ensure that the facility is in compliance with the section	1 2 3 4 5 6 7	The licensee will install new detectors and/or have electrician check system to ensure system is functioning properly.
	8 9 10 11 12 13 14	above. The facility smoke alarms were malfunctioning. This possess an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

LIC9099 (FAS) - (06/04)

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