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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609670
Report Date: 01/28/2025
Date Signed: 01/28/2025 02:33:33 PM

Document Has Been Signed on 01/28/2025 02:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:FAIR OAKS MANORFACILITY NUMBER:
197609670
ADMINISTRATOR/
DIRECTOR:		BONZON, TEDFACILITY TYPE:
735
ADDRESS:5035 ECHO STTELEPHONE:
(818) 846-4469
CITY:LOS ANGELESSTATE: CAZIP CODE:
90042
CAPACITY: 32CENSUS: 29DATE:
01/28/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Assistant Administrator Michael Bacolcol & Administrator Shahbaz BaigTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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At 9:50a.m. Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted unannounced case management visit to the facility. LPA Alvizar-Ettima met the assistant administrator and granted entry. At 10:10a.m. Administrator joined LPA Alvizar-Ettima and informed them the purpose of the visit was to follow up with the incident report submitted to the department regarding the client on client aggressive act.

On 01/21/2025 the Community Care Licensing Office received an incident report involving client #1 (C1) and client #2 (C2). The report indicates the following; On 01/19/25 client #3 (C3) and Client #1 (C1) were arguing when Client #2 (C2) intervened to calm C1 down. After C2’s intervention the argument escalated into the conflict between C1 and C2 and resulted in a physical altercation between C1 and C2. C2 pushed C3, who retaliated by head butting and punching C2. There were two (02) staffs that were present during argument. One the third staff arrived to the facility at 9:20 a.m. after the incident.

During this investigation at 10:10a.m. Assistant Administrator and LPA Alvizar-Ettima tour facility and did not observe any health and safety issues. At approximately 10:20a.m. LPA Alvizar-Ettima spoke with the Administrator, Assistant Administrator and other staff and discussed the details of the incident. At about 10:30a.m. LPA Alvizar-Ettima spoke with C2 and C3, who were present at the facility. Administrator indicated C1 no longer resides at the facility. Interviews indicated that at the time of incident at approximately 7:30a.m. C1 and C2 and two (02) staffs were present at the facility. Interviews revealed that C1 was being verbally aggressive with C3, staff and other clients. Staff revealed that when C1 and C2 started arguing and hitting each other, Staff #1 (S1) called 911 while staff #2 (S2) was shouting to C1 and C2 to stop fighting from the kitchen area. However, C1 and C2 stopped fighting on their own. Staff was unable to explain why staff allow the argument between C1 and C3 and did not take any steps to break the argument. Staff also were unable

Cont. LIC 9099c
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: FAIR OAKS MANOR
FACILITY NUMBER: 197609670
VISIT DATE: 01/28/2025
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to explain what they have done to prevent C2 to intervene, which could avoid physical altercation between C1 and C2.

Based on inspection, observation and interviews it was concluded that although staff was present during argument between C1, C3 and C2, they did not take appropriate steps to attempt to break an argument before it was escalated to the physical altercation.

Under Title 22 Regulations, the following citation is issued and recorded on LIC809D

No other health and safety hazard is noted during this visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/28/2025 02:33 PM - It Cannot Be Edited


Created By: Antonia Alvizar-Ettima On 01/28/2025 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: FAIR OAKS MANOR
FACILITY NUMBER: 197609670

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2025
Section Cited
CCR
80078(a)

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80078(a)Responsibility for Providing Care and Supervision The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by:
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Assistant Administrator indicated that they will provide in writting plan of what the facility is going do to ensure facility is protected at all times. Assistant Administrator will submit doucments to CCL by due date.
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There were two (02) staff present during argument between client to client and they did not take appropriate steps to attempt to break an argument before it was escalated to the physical altercation. This poses an immediate health and safety risk to clients 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.
SUPERVISOR'S NAME:Naira Margaryan
LICENSING EVALUATOR NAME:Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:
DATE: 01/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/28/2025


LIC809 (FAS) - (06/04)
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