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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609870
Report Date: 08/25/2021
Date Signed: 08/25/2021 10:27:05 AM

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
07/13/2021 and conducted by Evaluator LaQueena Lacy
COMPLAINT CONTROL NUMBER: 31-AS-20210713165720
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:
08/25/2021
UNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility did not report an incident to authorized representative.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) LaQueena Lacy, Melissa Ruiz and Angela Panushkina conducted an unannounced complaint visit to this facility to investigate the above allegation. LPAs were granted access by facility staff. LPAs met with the Administrator Saleem Mohammed and explained the purpose of this visit.
On 07/13/2021, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office, alleging that the facility client #1 (C1) left the facility unassisted and the incident was not reported to the appropriate agencies.

During investigation, LPAs conducted physical plant tour at 9:15 a.m.

At 9:19 a.m. LPAs spoke with the Administrator and he verified that within month of December 2020, C1 left the facility unassisted in two occasions. The Administrator admitted that they did not report the incidents to the Licensing Office and Regional Center, as they did not think that the reporting was necessary.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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 3
Control Number 31-AS-20210713165720
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
VISIT DATE: 08/25/2021
NARRATIVE
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At approximately 9:22 a.m. LPAs requested and reviewed various facility records. Facility had no records regarding C1’s unauthorized absences. Other records revealed that C1 is unable to leave facility unassisted.
Based on interviews and record review, it was concluded that the Administrator did not report the unusual incidents that may affect the health and safety of the client #1. Therefore, the allegation is substantiated at this time.
Based on Title 22 regulations, the following citation was issued and recorded on LIC 9099D.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20210713165720
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: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/27/2021
Section Cited
CCR
80061(b)(E)
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(b) Upon the occurrence, during the operation of the facility, of any of the events… a report shall be made to the licensing agency within the agency's next working day (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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Administrataor has added auditory alarms on windows and doors and moved C1 from room one (1) near laundry room to room three (3) furthiest from any exit doors.
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This requirement is not met as evidenced by; C1 left the facility unassisted 2 times and the Licensee failed to report the incidents to CCLD and to Regional Center. This poses a potential health and safety risk to clients in care.
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Staff has received in-service training on reporting requirements. Copies of trainings were obtained. This citation has been cleared during this visit.
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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: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3