197608341-8-15-2024-31-AS-HRAI-D86QDG-20240815120442

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608341
Report Date: 08/15/2024
Date Signed: 08/15/2024 12:05:30 PM

Document Has Been Signed on 08/15/2024 12:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BALCOM HOME		FACILITY NUMBER:	197608341
ADMINISTRATOR/ DIRECTOR:	MERCEDE SHAMLO		FACILITY TYPE:	735
ADDRESS:	7767 BALCOM AVE		TELEPHONE:	(818) 342-1001
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 4		CENSUS: 4	DATE:	08/15/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Mercede Shamlo, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:35 PM

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At 09:05 AM, on 08/15/2024, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced case management visit to this facility. LPA met with the staff who granted access to the facility. The Administrator was contacted and LPA disclosed the reason for the visit. Administrator arrived at the facility shortly after.

Today’s case management visit is to follow up on an incident previously reported on 08/12/24 by the facility in which Client #1 (C1) had a false positive pregnancy test as well as a behavioral episode which caused a bruise on the face (under the eyes) and a bump on the upper lip and nose. The purpose of the visit is to obtain additional information regarding this incident.

LPA interviewed Administrator, Staff #2 (S2), and a family member of C1 (via Administrator's phone) between 09:45 AM to 11:50 AM.

Continued on 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: BALCOM HOME	FACILITY NUMBER: 197608341
	VISIT DATE: 08/15/2024

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On 08/04/2024, C1 did not want to eat their breakfast. The staff gave time to C1 to eat their breakfast at a later time. At around 9:30 AM, staff provided C1's breakfast again. C1 threw their plate on the floor. As the staff was cleaning the floor, C1 hit their face on the table. The staff checked C1 for any injury and immediately applied the ice on C1's face. Initially, the self injurious behavioral episode caused a pump on C1's nose. Later, around the evening time C1 showed no bruising under eyes. C1 had a bump on their nose and upper lip mildly swollen. Staff applied more ice. On 08/05/2024, C1 had more visible bruise and a prominent nose bump. On 08/06/2024, C1's face showed more prominent discoloration under their eyes. The Administrator informed LPA that C1's parent was not surprised as C1 always had incidents as such in the past and always had bruises on their face or under the eyes afterwords. Interview with the family member of C1 confirmed the information.
On 08/09/2024, C1 had a scheduled dental procedure at UCLA. Before the dental procedure, UCLA had to do a blood work on C1 to check for the possibility of pregnancy. The blood lab test showed "positive for pregnancy" with HCG level of 8. The dental procedure was not done due to the "false positive test for pregnancy" as well as the bruises on C1's face which could have been a possible sexual assault. The Administrator took C1 to Kaiser Permanente urgent care on 08/09/2024, to confirm the pregnancy. On 08/11/2024, C1 was taken to Kaiser Permanente again for pregnancy test where it was revealed that C1 is not pregnant. Additionally, C1 was taken to a GYN appointment for further evaluation and testing for possible pregnancy on 08/13/2024. Based on the visits summary from 08/09/24, 08/11/24, and 08/13/24, C1 showed a false pregnancy test and is not pregnant. Additional lab tests are ready to be done on 08/15/2024. Furthermore, Administrator informed LPA that more thorough medical assessments of C1's overall health will be sought.

The Administrator reported the incident appropriately to Community Care Licensing (CCL), NLACRC, and Adult Protective Services (APS).

Since the Administrator has taken the appropriate actions, there are no deficiencies cited at this time.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024

LIC809 (FAS) - (06/04)

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