197609016-8-7-2022-31-AS-NMAN-CJ3KQE-20220908080613

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609016
Report Date: 08/07/2022
Date Signed: 08/07/2022 04:03:09 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., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2021 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20210112154754

FACILITY NAME:	ARK CARE HOME LLC		FACILITY NUMBER:	197609016
ADMINISTRATOR:	MANDAC, ADELAIDA Q		FACILITY TYPE:	740
ADDRESS:	37616 RIBBON LANE		TELEPHONE:	(661) 526-4066
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93552
CAPACITY:	6	CENSUS: 1	DATE:	08/07/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Richard Mandac		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Facility staff did not make cleaning solutions inaccessible to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. LPA arrived at 1:00 PM. Upon entry, LPA met with the co-administrator, Richard Mandac, was offered sanitizer, screened for COVID 19, and signed in. At the time of the visit, there were two staff and one resident present.

--- Facility staff did not make cleaning solutions inaccessible to residents

It was alleged that there was a cleanser bottle under the bathroom sink and cleansers under an unlocked kitchen sink. To investigate this allegation, on 08/07/2022 at 1:20 PM, LPA conducted a physical plant tour and, from 2:00 PM – 3:00 PM, LPA interviewed two staff and one resident. LPA’s observations from the physical plant tour revealed there were no cleaning supplies left unattended and that all toxins are locked away in a storage cabinet located in the kitchen.
(Cont. on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210112154754

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARK CARE HOME LLC	FACILITY NUMBER: 197609016
	VISIT DATE: 08/07/2022

NARRATIVE

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Furthermore, during interviews, staff stated that they do not leave cleaning supplies unattended and, when not in use, cleaning supplies are locked away. In addition, resident #1 (R1) also stated that they do not see cleaning supplies left unattended. Based on the observations and interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards were noted during the visit.

Exit interview was conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2022

LIC9099 (FAS) - (06/04)

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