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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609496
Report Date: 02/06/2026
Date Signed: 02/06/2026 03:10:33 PM

Substantiated


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
08/04/2025 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20250804081258
FACILITY NAME:ENCINO TERRACE SENIOR LIVINGFACILITY NUMBER:
197609496
ADMINISTRATOR:ROSE YOUSEFIANFACILITY TYPE:
740
ADDRESS:16025 VENTURA BLVDTELEPHONE:
(818) 986-8466
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY:85CENSUS: DATE:
02/06/2026
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Henry Reyes, Business office Manager/DesigneeTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Licensee does not ensure facility has sufficient staffing to meet the care needs of residents

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced complaint visit to this facility to deliver findings. LPA Smith was greeted by staff and disclosed the purpose of the visit.

At 10:10 am on 01/07/26, LPA Smith requested documents relevant to the investigation to include but not limited to a copy of admissions agreement, Personnel Report, Staff schedule, Resident roster. LPA Smith conducted interviews with the administrator and three (3) residents from approximately 11:10 am -1:10 pm.

Licensee does not ensure facility has sufficient staffing to meet the care needs of residents

In regard to staffing, interviews with the administrator revealed does not agree with the allegation and revealed the same number of caregivers have been employed at the facility for several years. Review of personnel report shows 20 resident assistants/coordinators that assist residents and

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
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 5
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
08/04/2025 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20250804081258

FACILITY NAME:ENCINO TERRACE SENIOR LIVINGFACILITY NUMBER:
197609496
ADMINISTRATOR:ROSE YOUSEFIANFACILITY TYPE:
740
ADDRESS:16025 VENTURA BLVDTELEPHONE:
(818) 986-8466
CITY:ENCINOSTATE: CAZIP CODE:
91436
CAPACITY:85CENSUS: 60DATE:
02/06/2026
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Henry Reyes, Business Office Manager/DesigneeTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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9
Staff did not ensure supervision was provided resulting in a resident entering another residents bed without consent
Staff do not observe changes in residents health conditions
INVESTIGATION FINDINGS:
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At 10:10 am on 01/07/26, LPA Smith requested documents relevant to the investigation to include but not limited to a copy of admissions agreement, Personnel Report, Staff schedule, Resident roster. LPA Smith conducted interviews with the administrator and three (3) residents from approximately 11:10 am -1:10 pm.

Staff did not ensure supervision was provided resulting in a resident entering another resident’s bed without consent
It was alleged that Staff did not ensure supervision was provided resulting in a resident entering another resident’s bed without consent. To investigate the allegations on 8/13/25, LPA Smith conducted a 10-day visit at which time LPA Smith requested documents relevant to the investigation, interviewed with the administrator and three (3) residents. On 12/04/25/21/25 LPA Smith delivered findings for two (2) of five (5) allegations. During interviews staff denied the above allegation above revealing staff supervise residents while in common areas and while performing duties such as medication admininstration and housekeeping.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20250804081258
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: ENCINO TERRACE SENIOR LIVING
FACILITY NUMBER: 197609496
VISIT DATE: 02/06/2026
NARRATIVE
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 (Cont from 9099A)

Interview with S2 reveal was assisting resident #3 (R3) in their room when resident #2 (R2) opened door by accident and immediately apologized for opening the wrong door. Staff reveal R3 did not get into R3 bed nor did R3 scream and run out of their room. Interview with administrator revealed follow-up was conducted with R2 who admitted to having a beverage containing alcohol prior to coming back to the facility and heading to their room. Administrator also stated supervision is not one-on-one, but staff are present in facility providing supervision. Interview with R3 revealed that they opened the wrong door on the way to their room but denied getting into R3’s bed. LPA was unable to interview R3 as residents no longer reside at the facility.
A review of R3’s physician’s report notes mild cognitive impairment however R3 assessment notes independent and ambulates independently. Based on the information obtained from interviews and record review, there is not enough information to verify the allegation, therefore the allegation is UNSUBSTANTIATED at this time.

Staff do not observe changes in resident health conditions

It is alleged that staff do not observe changes in resident health. Interview with administrator revealed that residents are observed by staff during regular interactions and medical attention is provided when requested or needed. Administrator also revealed that R3 no longer resides at the facility due to them experiencing various changes in behavior and/or health and required higher level of care. Interviews with three (3) out of three (3) staff reveal records are noted and LIC 624’s are sent to Licensing when changes occur in the residents’ health/behavior, or they require hospital transport. Review of LIC 624s verify that staff are documenting and observing changes in residents. LPA Smith observed staff checking on resident in lobby. Based on interviews, record review, and observation, this allegation is deemed Unsubstantiated at this time.

Exit Interview conducted/Copy of report given.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20250804081258
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: ENCINO TERRACE SENIOR LIVING
FACILITY NUMBER: 197609496
VISIT DATE: 02/06/2026
NARRATIVE
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(cont from 9099)
and staff schedule reveal the following:

Three (3) caregivers on the AM shift (6:00 - 2:00 pm), three (3) caregivers on the PM shift (2:00 - 10:00 pm), and three (3) caregivers on the NOC shift (1000 pm - 6:00 am)

Review of personnel report dated from July 2025 shows a total of 10 caregivers assigned and personnel report from Aug 2025 shows a total of 11 caregivers.

According to the administrator, they currently have a staffing ratio of 4 caregivers on the AM shift, 3 caregivers on the PM shift and 3 caregivers on the NOC shift.

However during complaint visit on 01/11/26 there were only two (2) staff available to provide assistance to residents and at least one (1) resident requires a two (2) person assistance with Activities of Daily Living (ADLs), such as bathing and toileting. Interview with two (2) staff reveal have informed licensee of additional staff needs.

Based on the information obtained, there is enough information to verify the allegation, therefore the allegation is SUBSTANTIATED at this time.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20250804081258
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: ENCINO TERRACE SENIOR LIVING
FACILITY NUMBER: 197609496
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/17/1984
Section Cited
CCR
87411(a)
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Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement has not been met based on:
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Licensee will ensure additional staff is hiired if required. The staff schedule and written information must be provided explaining the steps taken by the Administrator.
POC:02/20/26
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Interviews staff informed licensee need more staff/only two staff on Sunday Pm for resident assistance which poses health and safety risk to the residents in care.

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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: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5