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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607701
Report Date: 10/23/2023
Date Signed: 10/23/2023 04:31:11 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
10/19/2023 and conducted by Evaluator Antonia Alvizar
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20231019154801
FACILITY NAME:EASTER SEALS SOUTHERN CALIFORNIA DEBRA HOMEFACILITY NUMBER:
197607701
ADMINISTRATOR:VEGA TAPIA, DANNYFACILITY TYPE:
735
ADDRESS:10101 DEBRA AVETELEPHONE:
(818) 894-6938
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:4CENSUS: 4DATE:
10/23/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Staff confined resident to a room
INVESTIGATION FINDINGS:
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At 11:15 a.m. Licensing Program Analysts (LPA) Antonia Alvizar arrived to the facility to conduct an initial complaint visit. Upon arrival, LPA was greeted by staff Louis Mendoza and later met the Director, Danny Tapia and Administrator, Barabra Pacheco. LPA explained the purpose of the visit. At 11:56 p.m. staff Christopher Castro and LPA conducted a physical plant tour of facility.

Staff confined resident to a room

It is alleged that staff isolated client (C1) and forced to remain in bedroom because of throwing a toaster in the morning . Based on interviews, it was revealed that staff do not keep clients isolated in bedroom against clients will. An interview with Staff S1 indicated they verbally redirect C1 by giving them choices to stay in the living room, dining room, entertainment room, activity room, outside, or bedroom. LPA Alvizar reviewed Target Behavior record and verified the information provided by staff was correct.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
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-20231019154801
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: EASTER SEALS SOUTHERN CALIFORNIA DEBRA HOME
FACILITY NUMBER: 197607701
VISIT DATE: 10/23/2023
NARRATIVE
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Based on interviews obtained and record review, there was not enough evidence to support the allegation resident/client sustained injuries in care, so the allegation is deemed unsubstantiated.

No deficiencies issued.
Report signed and delivered to the Administrator Pacheco.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2