197609870-7-22-2022-31-AS-EMIR-CNCTUD-20230123140208

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609870
Report Date: 07/22/2022
Date Signed: 07/22/2022 01:40:08 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
11/12/2020 and conducted by Evaluator Melissa Ruiz

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20201112143937

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:	07/22/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mohammed Saleem		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff hit resident

INVESTIGATION FINDINGS:

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On 7/22/2022 at 10:00 a.m., Licensing Program Analysts (LPAs) Melissa Ruiz and Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival, LPAs were greeted by staff (S2) and S2 allowed entrance to the facility. LPAs later met with the Administrator, Saleem and an entrance interview was conducted, and the purpose of the visit was explained.

It was alleged that a staff hit resident.

On 11/13/2020, LPA Berry conducted an initial 10-day virtual visit to address this complaint. Due to the situation surrounding COVID-19, the visit was done virtually via FaceTime. During this virtual visit, LPA Berry requested various documents pertinent to this investigation. Prior to today’s visit, LPA Ruiz conducted interviews with three (3) credible witnesses on 7/18/222, all of which stated that on 11/12/2020, during a live zoom class, they saw a staff member (S1) physically hit a client (C1) with S1’s hand in the face. (cont. on LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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-20201112143937

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: 07/22/2022

NARRATIVE

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LPA Ruiz conducted an interview with the Administrator, and Administrator stated that although S1 denied the allegation occurred, S1 was put on leave until the investigation was finished. Administrator also stated that S1 was tired of waiting and quit and has not returned to work at the facility since the incident.

Based on interviews conducted and credible witness’ observations, the allegation staff hit resident is substantiated at this time.

Deficiencies were issued per CA code of Regulations Title 22. See 9099D's included with this report. Appeal rights issued. Report signed and delivered. Exit interview conducted.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
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)

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Control Number 31-AS-20201112143937

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: 07/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/24/2022 Section Cited CCR 80072(a)(2)	1 2 3 4 5 6 7	80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (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	Staff (S1) no longer works in the facility. The licensee/Administrator will initiate the process to disassociate S1 from the facility through Guardian. Proof will be sent by the POC due date of 7/24/22.
	8 9 10 11 12 13 14	Based on interviews, the licensee/administrator did not comply with the section cited above, in which three (3) credible witnesses observed S1 hit C1 in the face with S1’s hand . This poses an immediate health and safety risk or personal rights risk to clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
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

LIC9099 (FAS) - (06/04)

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