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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609870
Report Date: 07/22/2022
Date Signed: 07/22/2022 01:45:07 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2022 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220712163711
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
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Saleem MohammedTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident sustained injuries while in care.
INVESTIGATION FINDINGS:
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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. Upon arrival, LPAs were greeted by staff (S2) and LPAs later met with the Administrator Saleem. LPA Rios conducted an entrance interview, and the purpose of the visit was explained.

Regarding the allegation, it was alleged that a resident/client sustained injuries while in care. To aid this investigation, LPAs interviewed staff, the administrator and other credible witnesses. Based on interviews, it was revealed that on 7/12/22 there was an incident with client #1 (C1) and their shirt. Staff #1 (S1) stated they were working the morning with C1 and that C1 was in a bad mood and did not want to wake up or shower. S1 stated C1 got mad when S1 told them to get ready for school. C1 returned to their room and got dressed. When C1 came out of their room, C1's shirt was backwards. S1 told C1 to fix their shirt and C1 proceeded to twist the shirt around aggressively to fix it. S1 did not check or observe any markings or iinjuries on C1. LPA Rios reviewed the daily behavior notes at 10:30 regarding C1 and LPA Rios did note that there was an entry for that date reflecting the incident mentioned above.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20220712163711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 197609870
VISIT DATE: 07/22/2022
NARRATIVE
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An interview with staff #2 (S2) also corroborates that C1 was in a bad mood and did not want to get ready for school. Additionally, S2 did not see any injuries or markings when they walked C1 to the school bus that same morning. A credible witness stated that on that same morning of 7/12/22 they did not observe any markings on C1 during transportation from the facility to school. The credible witness also denied that any incident occurred during the transportation period that may have caused an injury to C1.

A visit from North Los Angeles Regional Center (NLARC) Community Service Specialist (CSS) Rowena DeGuzman on 7/19/22 corroborates no markings or injuries were visible. Furthermore, the CSS attempted to interview C1 (due to C1 being nonverbal) and C1 did not signal any concern or issues.

Based on interviews obtained and record review, there was not enough evidence to support the allegation resident/client sustained injuries in care, so the allegation is deemed unsubstantiated.

No deficiencies issued. Report 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2