197609496-2-28-2026-31-AS-NMAN-DWETN7-20260728145217

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609496
Report Date: 02/28/2026
Date Signed: 02/28/2026 04:21:47 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
11/25/2025 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20251125160009

FACILITY NAME:	ENCINO TERRACE SENIOR LIVING		FACILITY NUMBER:	197609496
ADMINISTRATOR:	ROSE YOUSEFIAN		FACILITY TYPE:	740
ADDRESS:	16025 VENTURA BLVD		TELEPHONE:	(818) 986-8466
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY:	85	CENSUS: 61	DATE:	02/28/2026
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Lhea Ramos, Front Reception		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Staff did not protect a cognitively impaired resident from repeated inappropriate contact by another resident
Staff does not ensure residents are treated with dignity and respect in their personal relationships with other residents
Staff did not ensure reporting requirements were followed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith and Licensing Program Manager (LPM) Naira Margaryan conducted unannounced subsequent complaint visit to the facility to complete an investigation for the above noted allegations. The Executive Director (ED) or the designee was not available during the visit. After waiting in the lobby for about 20 min, licensing staff met with the maintenance supervisor, who contacted the Licensee representative over the phone. The Licensee Representative and Vice President of Operation (VPO) arrived later.
During initial visit LPA Smith interviewed two (2) staff and three (3) residents from 10:45 AM to 3:15 PM. LPA Smith toured the facility at approximately 12:15 PM between interviews and requested copies of facility documents relevant to the investigation to include but not limited to personnel report, client register, physician reports at approximately 1:10 PM. Prior to this visit during other licensing visits, LPA Smith interviewed four (04) additional residents and on 12/26/25 LPA spoke with party relevant to the investigation over the phone. On 02/13/26, LPA Smith reviewed records obtained from the facility.

Staff did not protect a cogitively impaired resident from repeated inappropriate contact by another resident

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2026

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-20251125160009

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: 02/28/2026

NARRATIVE

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(cont from 9099C)

Staff did not ensure reporting requirements were followed
Regarding the allegation above, It was reported that R3 made several attempts to report incidents concerning R1 and R2. Staff failed to report the incident so R3 reported it. During interviews, ED and facility staff indicated that no one reported an incident involving R1 and R2 and did not observe any untoward behavior between R1 and R2. Therefore, there was nothing to report to R1 and R2s responsible parties, doctors or to appropriate agencies. During interview, R3 was unable to clarify who they reported an incident to at the facility. Other residents stated that they are able to communicate with staff and will report any emergencies or issues to staff, including going to front desk reception to report issues that require immediate attention.
During today’s visit licensing staff witnessed a resident reporting an issue regarding their emergency pendant. No records were available to verify an incident involving R1 and R2.

Based on interviews and record review, there is insufficient evidence to support the allegation above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

No issues/hazards observed during brief visit to deliver report.

Exit interview conducted/Copy of report sent.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2026

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20251125160009

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: 02/28/2026

NARRATIVE

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(cont from 9099)
Staff did not protect a cognitively impaired resident from repeated inappropriate contact by another resident
It was alleged that Resident #1 (R1), who has cognitive impairment, was taken advantage of in a sexual manner by Resident #2 (R2), who does not have cognitive impairment. Staff revealed that they had no knowledge of any incidents of inappropriate or sexual contact made by R2 towards R1.
R2 denied taking advantage of R1. LPA Smith attempted to interview R1, but they were unable to respond to the questions. Residents denied seeing inappropriate interactions between R1 and R2 or between other residents. Interview with party relevant to the investigation did not provide any concrete and verifiable information to support the allegation. A review of facility records did not reveal any information to verify the allegation.

Based on interviews and record review, there is insufficient evidence to support the allegation above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Staff does not ensure residents are treated with dignity and respect in their personal relationships with other residents

Concerns were addressed that Resident #3 (R3) was attempting to report incidents at the facility and was ignored by staff. The ED and staff denied ignoring or any untoward behavior toward residents. They revealed that they are all respectful to all residents and no resident came to report any incident(s) to them regarding the allegations. R3 was interviewed and was unable to clarify staff they reported incident(s) to, and which staff were ignoring them. The residents interviewed indicated that they are being treated with dignity and respect. Review of licensing records and facility incident reports did not reveal any information to support the allegation.

Based on interviews and record review, there is insufficient evidence to support the allegation above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2026

LIC9099 (FAS) - (06/04)

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