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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609670
Report Date: 12/01/2021
Date Signed: 12/02/2021 02:14:26 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
11/24/2021 and conducted by Evaluator Rosaura Valenzuela
COMPLAINT CONTROL NUMBER: 31-AS-20211124111634
FACILITY NAME:FAIR OAKS MANORFACILITY NUMBER:
197609670
ADMINISTRATOR:BONZON, TEDFACILITY TYPE:
735
ADDRESS:5035 ECHO STTELEPHONE:
(818) 846-4469
CITY:LOS ANGELESSTATE: CAZIP CODE:
90042
CAPACITY:32CENSUS: 31DATE:
12/01/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Shabaz Baig, AdministratorTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility is in disrepair

Facility does not provide paper towels in the bathrooms.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced complaint visit to the facility. LPA met with Shabaz Baig and explained the purpose of the visit.

It was reported that the facility is in disrepair. To investigate the allegation on December 1, 2021 at 10:47am, LPA conducted a physical plant tour of the facility with the administrator. LPA observed the screen in the t.v. room to be torn. LPA inspected all client rooms. Room numbers 3, 4, 7, 8 ,9, 10, 12, and 18, had windows that were non functional. The windows were either broken, missing screens, or about to fall off. LPA also observed a closet on the second floor to be broken. Rooms 2, 9, and 12 had broken furniture pieces. Based on observation, this allegation is going to be SUBSTANTIATED.

It was reported that facility does not provide paper towels in the bathrooms. To investigate this allegation, LPA inspected all of the bathrooms and observed that indeed there were no paper towels. LPA interviewed
continuation-see C 9099.











Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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-20211124111634
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: FAIR OAKS MANOR
FACILITY NUMBER: 197609670
VISIT DATE: 12/01/2021
NARRATIVE
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staff. Staff interviews revealed that paper towels are not placed in the bathrooms because clients clog the toilets. Based on observation and interviews the allegation will be SUBSTANTIATED.

The following deficiencies were cited per CA Code of Regulations, Title 22 - Refer to LIC 9099-D.

Appeal Rights Discussed/Exit Interview was conducted. Report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20211124111634
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: FAIR OAKS MANOR
FACILITY NUMBER: 197609670
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2021
Section Cited
CCR
80087(a)
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80087 Buildings and Grounds-(a) The facility shall be clean, safe, sanitrary and in good repair at all times for the safety and well-being of clients, employees, and visitors.

This requirement was not met as evidenced by:
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The licensee shall inspect all the rooms and repair in two weeks all items that are in disrepair. Licensee will provide pictures and invoices of all work that was completed and send to licensing by 12/15/21.
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Based on observation the Licensee failed to ensure that the facility be safe and in good repair at tall times. LPA observed the windows in rooms 3,4,7,8,9,10,12, and 18 to be non-fuctional. Windows were broken, missing screens, and about to fall off. A closet on the second floor is broken. Furniture in rooms 2,9, and 12 was broken. This poses a potential health and safety risk for clients in care.
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Type B
12/08/2021
Section Cited
CCR
80072(a)(2)
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80072 (a)(2) Personal Rights- To be accorded safe, healthful,and comfortable accomodations, furnishings, and equipment to meet his or her nedds.

This requirement was not met as evidenced by:
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Licensee will put paper towels in all bathrooms Licensee will send pictures to licensing showing that paper towels are made available in every bathroom by 12/08/21.
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Based on observation and interviews the Licensee failed to ensure that paper towels be installed in all the bathrooms
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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: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3