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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609870
Report Date: 09/29/2021
Date Signed: 09/29/2021 03:18:29 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
09/27/2021 and conducted by Evaluator Alexander Pitz
COMPLAINT CONTROL NUMBER: 31-AS-20210927120203
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: 4DATE:
09/29/2021
UNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Saleem MohammedTIME COMPLETED:
01:58 PM
ALLEGATION(S):
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Staff did not prevent a client from wandering while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegation.
As part of this investigation, LPA interviewed the co-complainant on 9/28/21 telephonically; interviewed the complainant on 9/29/21; interviewed the administrator on 9/29/21 at the facility; reviewed client 1's (C1's file) on 9/29/21.
Allegation #1, that "staff did not prevent a client from wandering while in care," has been substantiated based on the interviews conducted and records reviewed. A review of C1's Individual Program Plan (IPP) indicates that C1 requires supervision when outside of the facility, and has a history of elopement. The administrator confirmed on 9/29/21 that C1 eloped from the faciltiy on 9/26/21 at approximately 3:00 a.m., and was eventually brought back to the faciilty by a neighbor. LPA confirmed that this is the third instance of C1 eloping from the faciltiy within the last year.
Report reviewed, signed and deliverd. Exit interview conducted, deficiency cited on 9099D page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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-20210927120203
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: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2021
Section Cited
CCR
80065(a)
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80065(a)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 has terminated the staff on duty at the time of elopement and has installed additional alarms on the facility's doors. Administrator will also provide a staffing schedule and plan which explains how the facility will ensure adequate supervision during night staff's breaks.
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Based on interviews and record review, the facility did not properly supervise C1, which allowed C1 to leave the facility unassisted which poses an immediate risk to the health, safety or personal rights of residents 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: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2