197609057-9-30-2022-31-AS-CHAS-CKN29H-20221028171157

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609057
Report Date: 09/30/2022
Date Signed: 09/30/2022 10:29:40 AM

Unfounded

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
09/29/2022 and conducted by Evaluator Wendell Smith

COMPLAINT CONTROL NUMBER: 31-AS-20220929122756

FACILITY NAME:	PRIMROSE 2		FACILITY NUMBER:	197609057
ADMINISTRATOR:	NAIMUDDIN, MUBEEN		FACILITY TYPE:	740
ADDRESS:	8115 DE SOTO AVE		TELEPHONE:	(323) 387-2755
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91304
CAPACITY:	6	CENSUS: 6	DATE:	09/30/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Mubeen Naimuddin		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff mismanaged resident medication

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith made an unannounced complaint visit to investigate the allegation above. LPA met with facility staff and explained the reason for this visit.

Regarding the allegation above it is alleged that resident #1 (R1) was given another resident's medication by facility staff. LPA spoke with the administrator regarding this incident. Information from interview revealed that R1 does not reside in this facility but resides in Primrose (197609023) which is next door to this facility. Based on that a complaint will be written for Primrose (197609023) and this complaint will be Unfounded, means that the allegation is false, could not have happened, and/or is without a reasonable basis.
Exit Interview conducted.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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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