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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609500
Report Date: 03/03/2025
Date Signed: 03/03/2025 12:05:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
02/28/2025 and conducted by Evaluator Gina Saucedo
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20250228154456
FACILITY NAME:DEVONSHIRE ELDERLY CAREFACILITY NUMBER:
197609500
ADMINISTRATOR:BANGASH, FARAHFACILITY TYPE:
740
ADDRESS:17441 DEVONSHIRE STREETTELEPHONE:
(310) 955-0674
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 5DATE:
03/03/2025
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Farah Siddiqui, CaregiverTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff did not ensure leak was fixed properly
INVESTIGATION FINDINGS:
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On 03/03/25, at 9:40am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Farah Siddiqui, Caregiver. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The assistant administrator and administrator were called and informed of the visit.

The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 9:55am, LPA toured the physical plant. During the tour, LPA interviewed residents and staff.

9099C-continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
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 3
Control Number 31-AS-20250228154456
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
VISIT DATE: 03/03/2025
NARRATIVE
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Regarding the allegation: Staff did not ensure leak was fixed properly. It is being alleged that the downstairs hallway ceiling where residents walk under has water damage and a large hole. LPA interviewed three (3) residents that confirmed they saw the ceiling damaged but say it has now been repaired. LPA also interviewed three (3) staff that confirmed there was water leakage and a big hole in the ceiling due to water leaking from the upstairs. During LPA's physical tour, LPA observed the downstairs ceiling no longer has a hole but still shows the water damage. LPA took two (2) pictures of the ceiling. Therefore, based on the LPA's observations, resident and staff interviews, the above allegation(s) is SUBSTANTIATED at this time.

Exit interview was conducted, a citation(s) was issued for the above allegation(s), the appeals rights and a copy of this report was given to the Caregiver.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250228154456
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2025
Section Cited
CCR
87303(a)
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87303 (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This
requirement is not met as evidenced by:
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The licensee/administrator shall plaster/paint, the ceiling where the water/hole damage was located. The licensee/administrator shall send a picture/repair paperwork to the LPA.

POC due date: 03/19/25.
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Based on the LPA observation and interviews the licensee/administrator did not comply with the section cited above in one area that showed there was water damage, leaks to the ceiling which poses a Potential Health, Safety or Personal Rights risks to persons 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: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2025
LIC9099 (FAS) - (06/04)
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