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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609870
Report Date: 07/22/2022
Date Signed: 07/22/2022 01:48:54 PM

Document Has Been Signed on 07/22/2022 01:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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: DATE:
07/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Saleem MohammedTIME COMPLETED:
02:00 PM
NARRATIVE
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On 7/22/22 at 10:00 a.m. Licensing Program Analysts (LPAs) Evelin Rios and Melissa Ruiz arrived to the facility to conduct a subsequent complaint visit. At 10:20 a.m. during the course of a subsequent complaint investigation, LPA Rios conducted an interview with the Administrator. During the interview, the Administrator admitted that they did not report markings found on client #1 (C1) the day of 7/12/22 to the Licensing Office or Regional Center, within seven (7) days as they did not think that the reporting was necessary.

Based on the interview with the Administrator, deficiencies issued per CA Code of Regulations Title 22. This report was signed and delivered to the Administrator.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/22/2022 01:48 PM - It Cannot Be Edited


Created By: Evelin Rios On 07/22/2022 at 12:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASTHA HOME
FACILITY NUMBER: 197609870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited
CCR
80061E(b)

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80061E (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.
This requirement is not met as evidenced by;
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The Administrator has agreed to attend vendored training on reporting requirements and proof of training shall be submitted to the LPA by the POC due date.
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based on record review and interviews, the licensee/administrator did not ensure that a report was made within 7-days to CCLD or Regional Center regarding visible markings C1 had. This poses a potential health and safety risk to clients 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.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2022


LIC809 (FAS) - (06/04)
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