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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609704
Report Date: 11/05/2024
Date Signed: 11/05/2024 12:57:38 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
04/30/2024 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20240430142859
FACILITY NAME:SAFE LAUREL LLCFACILITY NUMBER:
197609704
ADMINISTRATOR:GBOYEGA AKINBOLAFACILITY TYPE:
735
ADDRESS:16300 VINTAGE STTELEPHONE:
(818) 489-1218
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:4CENSUS: 4DATE:
11/05/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cheryl PerkinsTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff left residents unattended
INVESTIGATION FINDINGS:
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At 12:30 p.m. on 11/05/24 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced subsequent complaint visit. LPA met with the licensee and disclosed the reason for the visit.

Regarding the allegation "Staff left residents unattended", it was alleged that on 03/20/24, Staff #1 (S1) left four (04) clients alone by themselves for 10-15 minutes. The facility self-reported this incident for the health and safety of all clients in the home.

During investigation on 05/06/24, from approximately 11:57 am to 1:35 pm, LPA Tihesha Smith toured the facility, interviewed three (3) staff and one (1) client, and requested and reviewed documents relevant to the investigation. These documents included, but were not limited to, the personnel report and the resident roster. LPA Smith was unable to interview three (3) clients as they were not present at the facility during time of visit.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
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 3
Control Number 31-AS-20240430142859
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: SAFE LAUREL LLC
FACILITY NUMBER: 197609704
VISIT DATE: 11/05/2024
NARRATIVE
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Interview with one (1) of four (4) clients revealed they had been left in the home alone with no other staff present. The client did not recall the date or the staff that left them in the home alone but believed the staff was female. Interview with three (3) of three (3) staff revealed they have not left clients unattended in the facility. However, two (2) of three (3) staff revealed that S1 left clients in the home alone on 03/20/24. Staff #2 (S2) revealed they arrived approximately five to ten minutes late to relieve S1 from the night shift. On arrival to the facility, S2 observed that S1 had already exited the facility and was in their vehicle before S2 was able to park and enter the facility. S2 also observed that no other staff was present in the facility and/or scheduled to work. Two (2) of three (3) staff also revealed that S1 no longer works at the facility.

Based on the information obtained, there is sufficient evidence to support the allegation. Therefore, the allegation is deemed substantiated at this time. A deficiency is cited on the corresponding LIC 9099-D page.

Exit Interview conducted. Appeal Rights explained. Copy of report given.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 31-AS-20240430142859
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: SAFE LAUREL LLC
FACILITY NUMBER: 197609704
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2024
Section Cited
CCR
80072(a)(2)
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80072 Personal Rights (a) ... each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations... to meet his/her needs. This requirement was not met as evidenced by:
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Licensee will provide memorandum to all staff referencing supervision requirements of the clients and staff shift change responsibilities. This documents must be signed by all staff and submitted to CCL by the POC date.
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Based on interviews and record review, the licensee did not comply with the section cited above through staff leaving clients unattended while no other staff were physically present in the facility which posed a potential risk to the Health, Safety, or Personal Rights of persons 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: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC9099 (FAS) - (06/04)
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