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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609870
Report Date: 08/11/2022
Date Signed: 08/11/2022 02:47:18 PM

Substantiated


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
08/04/2022 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220804153729
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:
08/11/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Saleem MuhammedTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility did not meet staffing requirements for residents in care.
Facility staff did not properly secure hazardous substances at the facility.
INVESTIGATION FINDINGS:
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An unannounced initial 10-day visit was conducted on 08/11/2022 by Evelin Rios Licensing Program Analyst (LPA) and Eva Miller Licensing Program Manager (LPM) to conduct an investigation. The allegations indicated the that North Los Angeles County Regional Center (NLACRC) conducted a visit on 07/19/2022 at which time it was observed that 1:1 client ratio for C#1 was out of compliance from 2:00pm-10:00pm. Additionally, during the unannounced visit conducted on 07/19/2022, it was observed that the lock on the cabinet under the sink where cleaning supplies and chemical solutions are stored, was not engaged and accessible to clients.
Allegation #1, Facility did not meet staffing requirements for residents in care. LPA Rios conducted an interview with Administrator. The following was determined. NLACRC personnel did arrive at the facility for an unannounced visit and observed that the staffing ratio was not being met at that time. Per the Administrator the incident did occur and has been corrected. Staffing was met on this date. Based on the information obtained, documents reviewed allegation #1 is Substantiated.The Plan of Correction has been met.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
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 3
Control Number 31-AS-20220804153729
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: 08/11/2022
NARRATIVE
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Allegation #2, Facility staff did not properly secure hazardous substances at the facility. LPA Rios conducted an interview with Administrator. The following was determined. NLACRC personnel did arrive at the facility for an unannounced visit and observed that the cabinet where they store cleaning supplies and chemical solutions was unlocked. Per the Administrator the incident did occur and has been corrected. Administrator locked the cabinet. Based on the information obtained, documents reviewed allegation #2 is Substantiated. On this date the LPA observed that the cabinet in question was locked. No other hazardous items were observed to be accessible to clients in care. The Plan of Correction has been met.
Exit interview conducted, citation, copy of report and appeal rights issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220804153729
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited
CCR
85065.5(a)(1)
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Day Staff-Client Ratio. For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients.
This requirement is not met as evidenced by:
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Administrator confirms that staffing ratios will be followed. A staff schedule for the next week will be submitted by 08/17/2022.
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Based on verbal admission by Administrator, the licensee failed to maintain the staff ratio as specified by the regional center as on 07/19/22 there were only 2 staff on duty from 2:00pm until 10:00pm which poses an immediate health and safety risk to residents in care.
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Type A
08/11/2022
Section Cited
CCR
80087(g)
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Buildings and Grounds: Buildings and Grounds. Disinfectants, cleaning solutions, poisons, and other items that could pose a danger to clients shall be inaccessible.
This requirement is not met as evidenced by:
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Deficiency has since been corrected. During the course of the day's visit, LPA observed that storage areas for items that can pose a danger to clients was maintained inaccessible. No further corrections required at this time.
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Based on verbal admission by Administrator the licensee failed to lock a cabinet that made cleaning solutions, and chemicals accessible to clients.
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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: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3