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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609683
Report Date: 11/26/2024
Date Signed: 11/26/2024 01:24:36 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.ASC, 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
10/02/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20241002112506
FACILITY NAME:LONE STAR BOARD & CARE TUJUNGAFACILITY NUMBER:
197609683
ADMINISTRATOR:ALEXANDER, OTISFACILITY TYPE:
735
ADDRESS:10117 TUJUNGA CANYON BLVDTELEPHONE:
(818) 875-4501
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:35CENSUS: 25DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Erika Stinson - Assistant AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility has insufficient food supply
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Gary Tan and Nadia Shahbazian conducted an unannounced subsequent visit at this facility to further investigate the above allegations. LPAs met with Assistant Administrator Erika Stinson who called the administrator Rod Stinson and explained the reason for the visit. Mr. Stinson designated Ms. Stinson to sign the report.

LPAs conducted physical plant tour at 10:02 AM, requested copies of facility documents relevant to the investigation at 10:30 AM, reviewed records between 10:30 AM to 11:30 AM and interviewed staff and residents between 11:30 AM to 12:30 PM. It was alleged that the food for the residents is scarce. LPAs observation during the physical plant tour today revealed that the facility did not have fresh fruits and vegetables in stock and the non-perishable food are insufficient for seven (7) days based on the current census. LPAs also observed the lunch being served today is not on the menu. Based on the information gathered during this and prior visit, the allegation is deemed substantiated at this time. Appeal rights explained and given. Exit interview conducted. Copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 4
Control Number 31-AS-20241002112506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LONE STAR BOARD & CARE TUJUNGA
FACILITY NUMBER: 197609683
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2024
Section Cited
CCR
80076(a)(1)
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All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Assistant Administrator agreed to purchase more food both perishable and non perishable including but not limited to fruit and vegatables and other nutritious foods for the residents and submit proof of purchase to CCLD and submit a signed statement that the facility will ensure to have enough food
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This requirement is not met as evidenced by:

Based on LPAs observation, the licensee failed to ensure that the food supply in the facility to meet the needs of the clients, this poses a potential health risk to the clients in care.
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in stock on a daily basis.
Type B
12/06/2024
Section Cited
CCR
80076(a)(5)
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Menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the clients or their authorized representatives and the licensing agency upon request.
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Assistant administrator agreed to inform the administrator to ensure that the facilty has sufficient food stock and to abide by the given menu and a sign statement to ensure that the facility will abide by the written menu and submit it to CCL on or before the POC date.
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Based on LPAs observation and interview, the licensee did not ensure that the menu is being followed for every meal that being served in the facility, this poses a potential health and safety risk to the 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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
10/02/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20241002112506

FACILITY NAME:LONE STAR BOARD & CARE TUJUNGAFACILITY NUMBER:
197609683
ADMINISTRATOR:ALEXANDER, OTISFACILITY TYPE:
735
ADDRESS:10117 TUJUNGA CANYON BLVDTELEPHONE:
(818) 875-4501
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:35CENSUS: 25DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:Erika Stinson - Assistant AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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9
Facility staff are not meeting clients dietary needs
INVESTIGATION FINDINGS:
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13
Licensing Program Analysts (LPAs) Gary Tan and Nadia Shahbazian conducted an unannounced subsequent visit at this facility to further investigate the above allegation. LPAs met with Assistant Administrator Erika Stinson who called the administrator Rod Stinson and explained the reason for the visit. Mr. Stinson designated Ms. Stinson to sign the report.

LPAs conducted physical plant tour at 10:02 AM, requested copies of facility documents relevant to the investigation at 10:30 AM, reviewed records between 10:30 AM to 11:30 AM and interviewed staff and residents between 11:30 AM to 12:30 PM. It was alleged that the Resident #1 (R1), Resident #2 (R2) and Resident #3 (R3)'s dietary restrictions are not being accommodated by the facility. LPAs record review today between 10:30 AM to 11:30 AM, revealed that all three (3) residents did not have dietary restrictions and no special diet ordered by their physicians. LPAs' interview with R1 today at 11:45 AM revealed that R1's food allergies are being accommodated by the kitchen staff and always provide R1 with a modified or totally different food being served to general population. (continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20241002112506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LONE STAR BOARD & CARE TUJUNGA
FACILITY NUMBER: 197609683
VISIT DATE: 11/26/2024
NARRATIVE
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(continued from LIC 9099)

LPA's interview with R2 on 10/08/24 between 10:30 AM to 12:30 PM also revealed that R2 did not have dietary restriction and the kitchen staff tried to accommodate R2's dietary needs as much as they could and R2 did not have any problem with the facility's food at this time. LPAs attempted to interview R3 but was asleep during visit.

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4