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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609683
Report Date: 06/08/2023
Date Signed: 06/08/2023 02:54:57 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
05/31/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20230531134458
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: 28DATE:
06/08/2023
UNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Gio Monico - Assistant AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Uncleared adults providing care to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced complaint visit at this facility to investigate the above allegation. LPA met with Gio Monico and explained the reason for the visit.

LPA conducted physical plant tour at 9:12 AM, requested copy of documents relevant to the investigation at 9:40 AM and interviewed staff between 10:02 AM to 11:00 AM. LPA also conducted record review between 11:00 AM to 12:00 PM. It was alleged that three (3) staff are working at the facility without fingerprint clearance. LPA's record review today revealed that Staff #1 (S1) and Staff #2 (S2) worked at the facility with pending fingerprint clearance, Staff #3 however, has a fingerprint clearance on file. LPA interview with Assistant Administrator today at 10:02 AM revealed that these three (3) employees indeed worked here but was removed upon review of the Guardian system on 05/23/23 wherein their status still shows pending. S2 is currently completing exemption papers and so do S1 but S3 no longer works at the facility. Based on the information gathered during this visit, the allegation is deemed substantiated at this time. Citation issued, civil penalty assessed, appeal rights discussed and given. Copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
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 2
Control Number 31-AS-20230531134458
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: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2023
Section Cited
CCR
87355(b)
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Criminal Record Clearance: Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption.
This requirement was not met as evidenced by:
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Cleared during visit. The assistant administrator removed them off schedule effective 05/23 and S3 quit effective 05/26.
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Based on LPA's record review and interview, Licensee failed to ensure that S1 & S2 had fingerprint clearance on file which poses an immediate health and safety of the residents 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: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2