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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608410
Report Date: 05/22/2025
Date Signed: 05/22/2025 03:48:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
05/01/2024 and conducted by Evaluator Erica Mosley
COMPLAINT CONTROL NUMBER: 29-AS-20240501092237
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:
05/22/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Selva Banos, Administrator
Alvard Yervandyan, Licensee Representative 		TIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Staff inappropriately forced residents out of the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above allegation. The purpose of this visit is to deliver findings for the above allegation. Upon arrival at 10:00 a.m., LPA Mosley was greeted by staff who called the Administrator. The Administrator arrived shortly after. The Licensee Representative arrived during the visit. The LPA met with Administrator, Selva Banos and Licensee Representative, Alvard Yervandyan.

On 05/01/2024 the Department received a complaint regarding the following allegation Staff inappropriately forced residents out of the facility. On 05/08/2024 LPA Yee conducted the initial 10-day complaint visit. LPA collected a copy of the on-the-job training logs, Identification and Emergency Information and conducted a short interview with the Administrator at 2:11pm.

Report continued on LIC 9099-C PAGE 2...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
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 29-AS-20240501092237
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAURELGROVE MANOR
FACILITY NUMBER: 197608410
VISIT DATE: 05/22/2025
NARRATIVE
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(Page 2) Report continued from LIC 9099...

During today’s visit, starting at 10:02 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns and facility is in compliance with Title 22 Regulations. Starting at 10:40 a.m. LPA conducted an in-person interview with two (2) staff, two (2) clients, starting at 12:44 p.m., conducted telephonic interviews with North Los Angeles County Regional Center (NLACRC), Community Service Specialist (CSS) Gabriela Pinzon and Resident #1 (R1), a file and record review and obtained copies of pertinent documents relevant to the investigation.

On the allegation Staff inappropriately forced residents out of the facility it is the concern of the reporting party (RP) that between 2015- 2020 the facility staff forced residents including R1 out of the facility during the day if they did not attend day program. To investigate this complaint, LPA conducted in-person interviews with two (2) staff, two (2) clients, telephonic interviews with North Los Angeles County Regional Center (NLACRC), Community Service Specialist (CSS) Gabriela Pinzon and R1 who no longer resides at the facility. Interview with Staff 1 (S1) revealed that the staff who they believe the allegation is in regard to is no longer at the facility and has not been at the facility for 5 years now. Interviews with residents revealed that between 2015 – 2020 facility staff forced them including R1 out of the facility during the day if they did not attend day program. Record review revealed that the facility was given a corrective action plan (CAP) from NLACRC on July 18, 2024, for the same allegation that was substantiated. Based on interviews and record review there is sufficient evidence to support the allegation occurred. Therefore, the allegation Staff inappropriately forced residents out of the facility is deemed substantiated at this time.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and / or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. Report was reviewed. A copy and appeal rights were issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 29-AS-20240501092237
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAURELGROVE MANOR
FACILITY NUMBER: 197608410
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2025
Section Cited
CCR
80078(a)
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80078(a) Responsibility for providing care and supervision: The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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Licensee submitted a staffing schedule with adequate staffing coverage per NLACRC ratio's on the day of the visit. POC cleared.
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Based on interviews the licensee did not comply with the section cited above in two (2) out of two (2) residents who resided at the facility between 2015 - 2020 staff forced them out of the facility during the day if they did not attend day program.
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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: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2025
LIC9099 (FAS) - (06/04)
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