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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609870
Report Date: 04/28/2021
Date Signed: 05/12/2022 12:33:24 PM

Substantiated


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
04/27/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210427143638
FACILITY NAME:ASTHA HOMEFACILITY NUMBER:
197609870
ADMINISTRATOR:MOHAMMED, SALEEMFACILITY TYPE:
735
ADDRESS:8839 GAVIOTA AVETELEPHONE:
(818) 387-5886
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:4CENSUS: 3DATE:
04/28/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Saleem MohammedTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Facility staff did not adequately supervise resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an initial complaint visit to this facility to investigate the allegation above. LPA met with administrator Saleem Mohammed and explained the reason for this visit.

It is alleged that client #1 (C1) has left the facility unattended on at least two occassions unsupervised. LPA conducted an interview with the administrator regarding this allegation from 10:05-10:25am. LPA reviewed C1's facility file which included C1's Individual Program Plan (IPP) from 10:30-10:45am. A review of C1's IPP revealed that C1's needs supervision when outside of the facility. Interview with administrator revealed that C1 did leave the facility unattended and went across the street. Administrator has notified North Los Angeles Regional Center about the incident. Administrator has spoken with Regional Center about C1 receiving one on one services. Based upon the information obtained this allegation is deemed Substantiated. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
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-20210427143638
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: ASTHA HOME
FACILITY NUMBER: 197609870
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/30/2021
Section Cited
CCR
80065(a)
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Personnel Requirements-Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement was not met as evidenced by:
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Administrator stated that they are meeting with the treatment team to request a one on one for C1 and facility staff will have training on supervision. Copy of sign in sheet of training on supervison will be provided to LPA upon completion.
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Based on interviews conducted facility staff did not properly supervise C1 which allowed C1 to leave the facility unattended which could have posed a health and safety risk to C1.
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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: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2