197609534-5-12-2025-31-AS-EMIR-DK3NCM-20250730102054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609534
Report Date: 05/12/2025
Date Signed: 05/12/2025 03:02:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
05/08/2025 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20250508145939

FACILITY NAME:	AZALEA GARDENS		FACILITY NUMBER:	197609534
ADMINISTRATOR:	ABDELKADER,FOOREVER C.		FACILITY TYPE:	740
ADDRESS:	6231 AZALEA DRIVE		TELEPHONE:	(661) 422-6160
CITY:	QUARTZ HILL	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 3	DATE:	05/12/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Khristine Campbell		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility does not have fire clearance for bedridden residents.
Facility has insufficient staffing.
Uncleared adults caring for residents.

INVESTIGATION FINDINGS:

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On 05/12/2025 at 10:30 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint investigation at the location mentioned above. LPA was greeted by Staff #1 (S1) who granted access. S1 called the administrator designee to inform them LPA was at the facility. LPA spoke to the administrator designee Khristine Campbell via facility telephone. Administrator designee informed LPA they would meet LPA at the facility. LPA explained to administrator designee the purpose of the visit.

At approximately 10:40 a.m., LPA conducted a physical plant tour of the facility and reviewed the facility sketch and facility's Fire Clearance (STD850). At 11:05 a.m., LPA reviewed Resident #1 (R1's) file and obtained copies of R1's Physician's Report, and Appraisal/Needs and Services. From approximately 11:25 a.m. to 11:44 a.m. LPA conducted an interviews with R1 and S1. Resident #2 (R2) did not respond to LPA's questions and resident #3 (R3) was asleep during the visit. At approximately 12:00 p.m., LPA met with the administrator designee and conducted an interview.
(Continue to LIC9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

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-20250508145939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AZALEA GARDENS	FACILITY NUMBER: 197609534
	VISIT DATE: 05/12/2025

NARRATIVE

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(Continued from LIC9099) LPA reviewed R2's and R3's record and obtained copies of R2's and R'3's, Physician's Reports, and Appraisal/Needs and Services.

Allegation: Facility does not have fire clearance for bedridden residents. In regards to the allegation, it was reported the facility had multiple bedridden residents without proper fire clearance. A review of facility's approved Fire Clearance completed on 03/02/2018, revealed that only room #5 is approved to retain a bedridden resident. Review of three (03) out of (03) residents' Physician's Report revealed that R1 is bedridden. During physical plant tour LPA Rios observed R1 in bedroom #1, which is not cleared for a bedridden resident. LPA's interview with the administrator designee revealed the physician's report was not filled out correctly and for the purpose of fire clearance R1 is non ambulatory as they only require assistance with transferring and not repositioning. According to the administrator designee a new report was being provided to the facility. LPA observed R1 in a wheelchair during visit. LPA's interview with R1 revealed they did not need assistance with repositioning. LPA was provided with a new copy of R1's Physician's Report with a status of non ambulatory. R2 and R3 who are non ambulatory based on their physician's report were in rooms designated for non ambulatory residents. Based on record review, observation, and interviews there was insufficient evidence to corroborate the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Allegation: Facility has insufficient staffing. In regards to the allegation, it was reported that the administrator designee is the only staff. Interviews with C1 and S1 reveal that they have no issues or concerns about staffing. Interview with R1 revealed they are fine with response time and have no issues with incontinent care. Interview with S1 revealed they have not witnessed soiled undergarments at the start of their shift. Interview with the administrator designee, denied the allegation. According to the administrator designee they work the night shift. Review of Personnel Report (LIC500) indicates that facility has two caregivers scheduled and a third caregiver on-call. Residents appraisal's do not indicate behaviors of wandering or sundowning. LPA observed residents to be clean, and the facility was free of odors from incontinence. Based on interviews, record review and observation, there was insufficient evidence to corroborate the allegation. Therefore, the findings are Unsubstantiated at this time.

(Continue to LIC9099-C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20250508145939

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AZALEA GARDENS	FACILITY NUMBER: 197609534
	VISIT DATE: 05/12/2025

NARRATIVE

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(Continued from LIC9099-C)

Allegation: Uncleared adults caring for residents. In regards to the allegation, it was reported that a staff has a criminal history and does not have fingerprint clearance. The reporting party identified this staff by their first name, but no last name or additional description given. During the complaint investigation, LPA was able to identify staff with the same first name, but could not confirm if this was the staff related to this allegation. LPA reviewed staff records and LIC500. All staff on LIC 500 were fingerprinted and background cleared. Interview with R1 and staff did not express any concerns about staff. Based on record review and interviews, there was insufficient evidence to corroborate the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

No other health and safety issues were observed at this time. Exit interview conducted, report signed and delivered.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025

LIC9099 (FAS) - (06/04)

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