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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608410
Report Date: 08/17/2021
Date Signed: 08/17/2021 02:48:27 PM

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. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/23/2020 and conducted by Evaluator Brian Balisi
COMPLAINT CONTROL NUMBER: 29-AS-20200623121546
FACILITY NAME:LAURELGROVE MANORFACILITY NUMBER:
197608410
ADMINISTRATOR:SELVA W BANOSFACILITY TYPE:
735
ADDRESS:7841 LAURELGROVE AVENUETELEPHONE:
(818) 255-4733
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY:4CENSUS: 4DATE:
08/17/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Selva W Banos - AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Lack of supervision resulting in residents engaging in physical altercations
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Brian Balisi and initiated a subsequent complaint investigation for the allegation listed above. LPAs met with Selva Banos and explained the reason for the visit.

During the investigation, LPA conducted physical plant tour virtually on 7/2/2021 as well as interviewed Administrator. On 8/9/2021, LPA conducted a physical plant, interviews with facility staff, residents and other relevant parties. LPA also gathered and reviewed facility documentation pertinent to the allegation.

It was alleged that Lack of supervision resulting in residents engaging in physical altercations, LPA interview with the residents in care revealed that all do not express any concerns of lack of supervision. All residents had stated there is always a staff member present inside of the home at all times.

(continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
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 29-AS-20200623121546
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAURELGROVE MANOR
FACILITY NUMBER: 197608410
VISIT DATE: 08/17/2021
NARRATIVE
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Continued from 9099

The residents also have not witnessed any physical altercations occur while in care at this facility. LPA records review of staff schedule also revealed there is at least (1) staff on duty in all shifts. Based on information gathered during this and previous visits, the department does not have any sufficient evidence to determine that there is a lack of supervision resulting in residents engaging in physical altercations. Therefore, the above allegation is UNSUBSTANTIATED at this time.

Exit interview conducted. Report issued and sent via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2