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Department of
SOCIAL SERVICES

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 LLCFACILITY NUMBER:
197609016
ADMINISTRATOR:MANDAC, ADELAIDA QFACILITY TYPE:
740
ADDRESS:37616 RIBBON LANETELEPHONE:
(661) 526-4066
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY:6CENSUS: 1DATE:
08/07/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Richard MandacTIME 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 MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (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)
Page: 1 of 2
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 MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (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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