197609870-10-7-2021-31-AS-EMIR-C8N26M-20211110160722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609870
Report Date: 10/07/2021
Date Signed: 10/07/2021 10:28:47 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
10/01/2021 and conducted by Evaluator Alexander Pitz

COMPLAINT CONTROL NUMBER: 31-AS-20211001112206

FACILITY NAME:	ASTHA HOME		FACILITY NUMBER:	197609870
ADMINISTRATOR:	MOHAMMED, SALEEM		FACILITY TYPE:	735
ADDRESS:	8839 GAVIOTA AVE		TELEPHONE:	(818) 387-5886
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	4	CENSUS: 4	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Cinthia Briceno		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Client does not have appropriate cover on mattress.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to the above allegations.
On 10/1/21 Community Care Licensing received a Corrective Action Plan (CAP) for this facility from the North Los Angeles County Regional Center (NLACRC). The CAP notes that on 9/21/21 NLACRC conducted a visit to the facility and observed the trash compactor to be broken and for Client 1’s (C1’s) box frame to still retain the factory plastic wrapping. On 10/7/21 LPA conducted a visit to the facility, interviewed staff and inspected both C1’s bed and the trash compactor.

Allegation #1, that “Client does not have appropriate cover on mattress,” has been substantiated based on the reporting of a credible party, the interviews conducted, and LPA’s observations. The NLACRC CAP indicates that on 9/27/21 the factory plastic mattress cover for C1 was still on the bed. LPA interviewed Staff1 and Staff 2 on 10/7/21 and they confirmed this.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20211001112206

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: 10/07/2021

NARRATIVE

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Allegation #2, that “Facility is in disrepair,” has been substantiated based on the reporting of a credible party, and the observations made by LPA. The NLACRC CAP indicates that on 9/27/21 the facility’s trash compactor was observed to be in disrepair. On 10/7/21 at 9:00am LPA visited the facility and made the same observation.

Report reviewed, signed and delivered. Exit interview conducted, deficiencies on 9099D page.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20211001112206

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: 10/07/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/07/2021 Section Cited CCR 80072(a)(2)	1 2 3 4 5 6 7	80072(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Plastic cover had been removed already prior to LPA's visit on 10/7/21, deficiency cleared on site.
	8 9 10 11 12 13 14	Based on the reporting of a credible party, the facility did not ensure that the plastic wrapping on C1's bed mattress was removed which poses a potential risk to the health, safety or personal rights of residents in care.	8 9 10 11 12 13 14
Type B 10/14/2021 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will provide proof of the trash compactor being repaired by the indicated date.
	8 9 10 11 12 13 14	Based on the reporting of a credible party and observations made by LPA on 10/7/21 at 9:00am, the faciltiy did not ensure that its trash compactor remained in good working condition which poses a potential risk to the health, safety or personal rights of residents in care.	8 9 10 11 12 13 14

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: 10/07/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC9099 (FAS) - (06/04)

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