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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608120
Report Date: 10/16/2024
Date Signed: 10/16/2024 02:10:30 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
10/10/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20241010132903
FACILITY NAME:CCLE HOME CARE, LLCFACILITY NUMBER:
197608120
ADMINISTRATOR:ROSANNA TOMENENGFACILITY TYPE:
735
ADDRESS:16055 NAPA STREETTELEPHONE:
(818) 830-7383
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:4CENSUS: 4DATE:
10/16/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lorenz Tomaneng- assistant administratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff did not treat client with respect.
Staff did not provide comfortable accommodations to client in care.
INVESTIGATION FINDINGS:
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13
Licensing Program Analysts (LPA) Leslie Ngo-Castaneda conducted an unannounced complaint visit to this facility to investigate the above allegations. LPA met with the facility staff Maria Smith, who granted access to the facility at 9:36AM. At 11:21 AM facility assistant administartor Lorenz Tomaneng arrived and was adviced the reason of the visit.

Entrance interview was conducted.

At approximately 9:37 AM, with the assistance of the staff LPA conducted a physical plant tour, to ensure the health and safety of the residents are protected and the physical plant is in compliance with Title 22 Regulations. During the investigation, interviews and record reviews were made. At 10:30AM, LPA requested the resident and staff roster. At 11:23 AM, LPA requested copies of pertinent information which include, but are not limited to an admission agreement, CSMDR, Physician’s Report, LIC 500, LIC 9020, and any document relevant to the investigation. Continue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
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 5
Control Number 31-AS-20241010132903
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: CCLE HOME CARE, LLC
FACILITY NUMBER: 197608120
VISIT DATE: 10/16/2024
NARRATIVE
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Allegation #1: Staff did not treat client with respect.

It is being alleged that staff failed to treat C1 with dignity and respect. A credible witness from North Los Angeles County Regional Center (NLACRC) was at the facility for their quarterly meeting when the allegation happened. During the investigation, LPA interviewed the assistant administrator, administrator on the phone, client #2 (C2), and staff #3 (S3). Based on interview and a review of documentation obtained, it was revealed that S4 did not treat C1 with respect.

Therefore, based on information obtained, the allegation is deemed substantiated.

Allegation #2: Staff did not provide comfortable accommodations to client in care.

It was alleged that facility is not providing a comfortable environment for residents. A credible witness from North Los Angeles County Regional Center (NLACRC) was at the facility for their quarterly meeting when the allegation happened. It is being alleged that the rooms at the end of the hallway on the left (C1 bedroom) and right (C2 bedroom) were too hot. LPA interview one (1) out of four (4) clients, administrator on the phone, and assistant administrator that the rooms at the end of the hallway confirmed that the bedrooms were warmer compared to other part of the facility. LPA also visited both bedrooms and it was revealed that it is definitely warmer were no fans were on site or air-conditioning being turned on.

Therefore, based on staff and client interviews the above allegation(s) is found to be substantiated.

An exit interview was conducted, citations were issues, appeal rights, and a copy of this report was given to the administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/10/2024 and conducted by Evaluator Leslie Ngo-Castaneda
COMPLAINT CONTROL NUMBER: 31-AS-20241010132903

FACILITY NAME:CCLE HOME CARE, LLCFACILITY NUMBER:
197608120
ADMINISTRATOR:ROSANNA TOMENENGFACILITY TYPE:
735
ADDRESS:16055 NAPA STREETTELEPHONE:
(818) 830-7383
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:4CENSUS: 4DATE:
10/16/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lorenz Tomaneng- assistant administratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate meals to client in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPA) Leslie Ngo-Castaneda conducted an unannounced complaint visit to this facility to investigate the above allegations. LPA met with the facility staff Maria Smith, who granted access to the facility at 9:36AM. At 11:21 AM facility assistant administartor Lorenz Tomaneng arrived and was adviced the reason of the visit.

Entrance interview was conducted.

At approximately 9:37 AM, with the assistance of the staff LPA conducted a physical plant tour, to ensure the health and safety of the residents are protected and the physical plant is in compliance with Title 22 Regulations. During the investigation, interviews and record reviews were made. At 10:30AM, LPA requested the resident and staff roster. At 11:23 AM, LPA requested copies of pertinent information which include, but are not limited to an admission agreement, CSMDR, Physician’s Report, LIC 500, LIC 9020, and any document relevant to the investigation. Continue to LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20241010132903
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: CCLE HOME CARE, LLC
FACILITY NUMBER: 197608120
VISIT DATE: 10/16/2024
NARRATIVE
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Regarding the allegation that the staff does not provide adequate food service. It was alleged that C1 would have salty, sweet and unhealthy meals. To investigate the allegation LPA witness S3 offered breakfast to C2, such as: pancakes, oatmeal, plantains, beans, eggs with toast, or cereal. C2 opt in for pancakes and S3 made four (4) pancakes from scratch. LPA interview C2 and stated that food is great, lots of vegetable, no can or frozen foods. LPA also obtain a a copy of facility dinner menu and observed a great variety of food was offered.

Exit interview conducted and copy of this report is given.

Based on observations, record reviews, and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20241010132903
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: CCLE HOME CARE, LLC
FACILITY NUMBER: 197608120
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2024
Section Cited
CCR
80072(a)(1)
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Personnel Rights-each client shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement was not met as evidenced by:
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Corrected before visit. S4 was suspended and according to administrator staff will not be returning to facility.
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Based on interviews conducted S4 spoke inappropriately to C1 which posed a potential health and safety risk to clients in care.
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Type B
10/30/2024
Section Cited
CCR
80072(a)(2)
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 80072 Personal Rights (a) […] each client shall have personal rights which include, but are not limited to, the following: rights: (2) to be accorded safe, healthful, and comfortable accommodations […] This requirement is not met as evidenced by:
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Licensee will make sure facility heating/cooling system is maintains in apppropriate temperatures for clients. Assistant Administrator provided a fan and turned on the AC unit.
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Based upon observation and interviews, the Administrator did not maintain a comfortable temperature within the bedroom as the heating and cooling system was not available.
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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: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5