197609057-3-16-2023-31-AS-NMAN-CRJVC4-20230505161830

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609057
Report Date: 03/16/2023
Date Signed: 03/16/2023 04:41:28 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
02/16/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230216083333

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:	03/16/2023
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Mubeen Naimuddin		TIME COMPLETED:	04:47 PM

ALLEGATION(S):

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Licensee not complying with terms of admission agreement

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at approximately 3:20 pm. LPA Smith met with facility staff and disclosed the purpose of this visit. The administrator was contacted and arrived later.
During initial visit on 02/21/22, LPA Smith conducted tour of physical plant, requested documents relevant to the investigation and conducted interview with administrator.

Licensee not complying with terms of admission agreement

It was alleged that the Licensee is not complying with terms of admission agreement. Interview with administrator revealed has complied with the admission’s agreement and also offered to provide a private room for Resident #1 (R1) in his other facility, Primrose, which offers awake at night services and is located next door to Primrose 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

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-20230216083333

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: PRIMROSE 2	FACILITY NUMBER: 197609057
	VISIT DATE: 03/16/2023

NARRATIVE

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(Cont from 9099)

Interview with administrator also reveal contacted R1 responsible party several times but have not had any success in obtaining a response in regard to collection/disposal of R1s belongings. LPA review of admissions agreement reveal the document to be missing signatures and/or initials of responsible party/licensee and Client/Resident Property and Valuables form only notes a hospital gown signed on 12/20/2020 by Licensee/Designated representative. Administrator revealed that due to responsible party not returning Client/Resident Property and Valuables form, he created new form to record R1 only had a hospital gown when admitted. Administrator revealed responsible party picked up R1s belongings today, 03/16/2023.

Based on the information gathered during interviews and record review there is insufficient pertinent information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2023

LIC9099 (FAS) - (06/04)

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