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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608053
Report Date: 01/15/2025
Date Signed: 01/15/2025 02:10:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
01/06/2025 and conducted by Evaluator Mariana Agban
COMPLAINT CONTROL NUMBER: 31-AS-20250106164839
FACILITY NAME:GREENWOODS RESIDENTIAL CARE, INC.FACILITY NUMBER:
197608053
ADMINISTRATOR:MARILEN M. BASAFACILITY TYPE:
735
ADDRESS:9606 GOTHIC AVETELEPHONE:
(818) 335-4143
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 6DATE:
01/15/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:MARILEN M. BASA- AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff hit client
Staff did not follow reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mariana Agban conducted an unannounced initial complaint visit to investigate the above stated allegations. LPA met with Administrator Marlien Basa and explained the reason for the visit. LPA conducted a physical plant tour, to ensure the health and safety of the clients were protected and the physical plant was in compliance with Title 22 Regulations. At approximately 10:00 AM, LPA requested clients and staff roster. LPA also requested copies of pertinent information which include, but are not limited to, Individual Program Plan (IPP), Physician Reports, and Admission Agreements. Today's investigation consisted of interviews with two (2) out of three (3) staff members and record reviews.

Allegation: Staff hit client
It was reported that Staff#1(S1) had hit Client#1(C1) on the face and head for not making the bed correctly. The date and time of the incident are unknown. North LA County Regional Center (NLCRC) Corrective Action Plan (CAP) indicated that Client#2 (C2) reported witnessing S1 hitting Client#3(C3) when C3 did not return to the room as directed. Interview with two (2) staff members denied witnessing those incidents.
(Continue on 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
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 4
Control Number 31-AS-20250106164839
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GREENWOODS RESIDENTIAL CARE, INC.
FACILITY NUMBER: 197608053
VISIT DATE: 01/15/2025
NARRATIVE
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Interview with S3 revealed that S1 was removed from the premises on 12/26/2024 upon acknowledge the issue and later resigned on 01/02/25. Based on information obtained the allegation is deemed Substantiated at this time.

Allegation: Staff did not follow reporting requirements
It was reported that S3 was informed about the incidents of C1 and C3 and did not submit a Special Incident Reports for either of these (2) incidents. LPA conducted file review and observed that there were no Special Incident Reports submitted to CCL. S3 has also failed to submit to CCL the required SOC 341 Report of Suspected Adult/Elder Abuse as a part of Assembly Bill 40(AB40) requirements. Facility staff was reminded to complete and submit SOC 341 upon suspecting any abuse at the facility. Based on information obtained the allegation is deemed Substantiated at this time.

Exit interview conducted, citation issued , an immediate civil penalty assessed, appeal rights provided and copy of this signed and delivered
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 31-AS-20250106164839
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREENWOODS RESIDENTIAL CARE, INC.
FACILITY NUMBER: 197608053
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/16/2025
Section Cited
CCR
80072(a)(3)
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80072(a)...each client shall have personal rights which include, but are not limited to, the following:(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation...
This requirement is not met as evidenced by:
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Once Administrator learned of the allegation S1 was removed from the premisis. The Administrator will conduct in service training reviewing this section of the regulation. The Administrator will provide attendace sheet of all staff that have attended the training by 01/23/25.
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Based on the North LA County Regional Center (NLCRC) Corrective Action Plan (CAP), substantiating physical abuse perpetrated by S1 on C1 and C3 which posed an immediate health and safety risk or personal rights risk to persons in care..
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An immediate $500 is assessed.
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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: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20250106164839
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GREENWOODS RESIDENTIAL CARE, INC.
FACILITY NUMBER: 197608053
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2025
Section Cited
CCR
87211(c)
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87211(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions
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The administrator will review Title 22 Regulations, Section 87211 on Reporting Requirements, and submit a SOC 341 to CCL regarding C1 and C3 incidents by the POC date.
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 Code Section 15630(b)(1). This requirement was not met as evidenced by: facility that did not submit to CCL SOC 341 Report of Suspected Adult/Elder Abuse as a part of Assembly Bill 40 requirements. This poses a potential health and safety risk to clients in care.
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Type B
01/23/2025
Section Cited
CCR
80061(b)
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80061(b) Reporting Requirements. Upon the occurrence…a report shall be made to the licensing agency..., a written report ...within seven days following the occurrence of such event.
This requirement was not met as evidence by:
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The administrator will submit 2 SIRs to CCL regarding C1 and C3 incidents by the POC date.
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Based on file document review, the Licensee did not comply with the section cited above. Lincesee didn't submit a SIR report for C1 and C3 reporting both physcial abuse incidents . This poses a potential health and safety risk to clients 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: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC9099 (FAS) - (06/04)
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