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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609807
Report Date: 04/23/2022
Date Signed: 04/23/2022 02:05:33 PM

Unsubstantiated


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
05/17/2021 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20210517090012
FACILITY NAME:SERENITY PATHWAYS, INCFACILITY NUMBER:
197609807
ADMINISTRATOR:ISIKO, FAITH NASSALIFACILITY TYPE:
735
ADDRESS:10522 CEDROS AVETELEPHONE:
(818) 274-2692
CITY:MISSION HILLSSTATE: CAZIP CODE:
91345
CAPACITY:4CENSUS: 3DATE:
04/23/2022
UNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Faith Isiko - AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff hit resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to deliver the findings for the above allegation. LPA met with Administrator Faith Isiko and explained the reason for today’s visit.

During the initial visit by LPA Avetisyan on 05/19/21 at 3:00 PM, LPA reviewed facility records, and interviewed facility staff and obtained copies of pertinent documents relevant to the investigation. Subsequent visit was made by LPA Tan on 04/03/22 at 8:50 AM, LPA conducted physical plant inspection at 9:08 AM and interviewed staff and residents between 10:00 AM to 12:00 PM. LPA also requested facility documents relevant to the investigation at 9:50 AM.

The Complainant alleged that Resident #1 (R1) was hit by Staff #1 (S1) in the hand after ripping R1’s clothes. LPA’s interview with residents at the facility on 04/03/22 between 10:00 AM to 12:00 PM, revealed that they did not witness nor hear any staff hurting or physically abusing R1. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2022
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-20210517090012
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: SERENITY PATHWAYS, INC
FACILITY NUMBER: 197609807
VISIT DATE: 04/23/2022
NARRATIVE
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(continued from LIC 9099)

During interview on 4/3/22, S1 denied harming or physically abusing any resident at the facility. LPA’s interview with the administrator designee on 04/03/22 at around 11:45 AM, also revealed that he did not witness nor receive any report of any physical abuse of any staff to any resident.

LPA’s record review on 04/03/22 at 1:15 PM revealed documentation that R1 had a long history of self-injurious behavior including ripping own clothes when having tantrums in or out of the facility. Based on the information gathered during the course of the investigation, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2