197607355-7-27-2022-31-AS-NMAN-CHBQ4X-20220815115101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607355
Report Date: 07/26/2022
Date Signed: 07/27/2022 09:29:26 AM

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
07/19/2022 and conducted by Evaluator Rosaura Valenzuela

COMPLAINT CONTROL NUMBER: 31-AS-20220719101212

FACILITY NAME:	THREE SYCAMORES ON GOULD		FACILITY NUMBER:	197607355
ADMINISTRATOR:	MARK YULE		FACILITY TYPE:	740
ADDRESS:	4701 GOULD AVENUE		TELEPHONE:	(818) 890-6111
CITY:	LA CANADA	STATE: CA	ZIP CODE:	91011
CAPACITY:	6	CENSUS: 5	DATE:	07/26/2022
		UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Mary Jane Mclleland, Assistant Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff is being rough with residents in care.

Staff files are incomplete

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced visit for the above noted allegations. LPA met with Mary Jane Mclleland, Assistant Administrator and explained the reason for the visit.

It was reported that staff is being rough with residents in care. To investigate this allegation on 07/26/2022 at 1:30pm, LPA initiated staff interviews. Interviews revealed that staff deny that they have seen or are aware of any facility employee not being gentle with residents in care. At 1:45pm, LPA interviewed residents. Interviews revealed that they have not seen staff being rough with residents. They stated that staff are helped and that they like to joke around.

Based on interviews there is not sufficient information to support this allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

Continue on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

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 31-AS-20220719101212

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: THREE SYCAMORES ON GOULD	FACILITY NUMBER: 197607355
	VISIT DATE: 07/26/2022

NARRATIVE

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It was alleged that staff files are incomplete. To investigate this allegation on 7/26/2022 at 2:20pm, LPA conducted records review. Personnel files were observed to be locked and available upon request. LPA reviewed records. Files contained employees information, health screening documents, finger print clearance, training certificates, and LIC 500. Files were complete

Based on records review and observation there is not sufficient information to support this allegation. Thus the allegation has been deemed UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC9099 (FAS) - (06/04)

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