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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609871
Report Date: 05/12/2026
Date Signed: 05/12/2026 02:57:14 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
05/05/2026 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20260505111640
FACILITY NAME:HEPZEBAH HOUSEFACILITY NUMBER:
197609871
ADMINISTRATOR:JACKSON, SYLVIAFACILITY TYPE:
740
ADDRESS:22230 VANOWEN STTELEPHONE:
(310) 213-4927
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91303
CAPACITY:6CENSUS: 5DATE:
05/12/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Sylvia Jackson, Administrator TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff left resident in a soiled brief
Staff did not provide first responder with resident's records
Licensee did not ensure front egress is free from obstruction
INVESTIGATION FINDINGS:
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At 10:30am, Licensing Program Analyst (LPA), Angela Panushkina conducted an unannounced visit in response to the above-mentioned allegations. LPA met with the Administrator and explained the reason for the visit.

At 10:35am, LPA requested residents and staff roster. At 10:40am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Incontinence Plan of Care, Staff Training relevant to the investigation. At approximately 10:50am, LPA conducted a physical plant tour. Between 10:55am – 12:00pm, LPA conducted an interview with the Administrator and two (2) out of four (4) residents, who were able to communicate.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
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 5
Control Number 31-AS-20260505111640
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: HEPZEBAH HOUSE
FACILITY NUMBER: 197609871
VISIT DATE: 05/12/2026
NARRATIVE
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Allegation: Staff left resident in a soiled brief

It was alleged that the staff left R1 in a soiled brief. To investigate this allegation, LPA contacted the credible witness on 05/08/26, who confirmed that they responded to the facility (9-1-1 call) on 05/03/2026 at approximately 10:00am, and R1 had reportedly complained of stomachache, and when the credible witness assessed R1, they observed R1 was wearing a soiled incontinent brief. During today’s visit, LPA conducted an interview with the Administrator and was informed all residents are checked and assisted with toileting/incontinence care throughout the day and as needed. However, on the date of an incident, there was limited staff available at the facility during the time 911 arrived. Interview with the Administrator also revealed that staff are expected to provide timely assistance with toileting and incontinent care. However, the Administrator was unable to explain as to why on the day of an incident, R1 was not changed and proper care was not provided. Therefore, based on the credible witness observation and Administrator confirmation this allegation is Substantiated.

Allegation: Staff did not provide first responder with resident's records

It was alleged that on 05/03/2026 staff did not provide a first responder with R1’s records. To investigate this allegation, LPA conducted an interview with the credible witness and was informed that upon arrival (911 call) at the facility, staff #1 (S1) did not appear to know R1’s basic information and were unable to locate or access R1’s facility file. LPA was also informed that it took several minutes for the Administrator to arrive who was able to write down R1’s biographical information before R1 was transferred to the hospital. Interview with the Administrator revealed that S1 was newly hired and did not have access to resident records. During the interview, the Administrator acknowledged that staff should have been able to provide residents basic information and records in a timely manner. Therefore, based on credible witness observation and information gathered during today’s visit, this allegation is Substantiated.

Continue on LIC9099-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20260505111640
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: HEPZEBAH HOUSE
FACILITY NUMBER: 197609871
VISIT DATE: 05/12/2026
NARRATIVE
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Allegation: Licensee did not ensure front egress is free from obstruction

It was alleged that the licensee did not ensure the front door was free from obstruction. To investigate this allegation, LPA contacted the credible witness on 05/08/26, who confirmed that when they responded to the facility (9-1-1 call) on 05/03/2026, it was difficult to exit the facility with R1 because there was furniture on the porch and a hose in the way. During today’s visit (upon arrival), LPA observed one (1) chair and one (1) table on the left side of the house (with no obstruction). However, LPA also observed the hose in the way by the ramp. Interview with the Administrator revealed that they placed the chair and the table outside in case residents have family/friends visiting they can sit outside and have privacy. Administrator also acknowledged that the walkway should remain clear and accessible at all times and that items such as outdoor furniture and hoses should not block the front entry, walkway or emergency exits pathway. The Administrator also acknowledge that on 05/03/26 the ramp was an obstructed by the hose and further stated that staff are expected to monitor the facility exterior and remove any items that may interfere with safe passage. Therefore, based on credible witness and LPA observation and information gathered during today’s visit, this allegation is Substantiated.

Deficiencies issued during today's visit.

Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20260505111640
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: HEPZEBAH HOUSE
FACILITY NUMBER: 197609871
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2026
Section Cited
CCR
87464(a)
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Basic Services: (a) The services... shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care...
This requirement is not met as evidenced by:
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The Administrator agreed to create an Incontinent Plan of Care and provide
in-service training to all current and future staff members. Proof of training will be submitted to LPA by POC date.
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Based on the credible witnesses visit conducted on 05/03/26, the licensee did not comply with the section cited above by not changing R1's soiled incontinence brief, which posed a potential health, safety, and personal rights risk to persons in care.
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Type B
05/19/2026
Section Cited
CCR
87465(f)(1)
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Incidental Medical...: Emergency care requirements shall include the following: (1) The name, address, telephone number of each resident's physician... shall be readily available to... and facility staff.
This requirement is not met as evidenced by:
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Administrator agreed to create an emergency card for residents that will be used/provided to first responders. Also in-service training will be conducted with all staff and copies will be submitted to LPA by POC date.
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Based on credible witnesses visit conducted on 05/03/26, licensee did not comply with the section cited above by failing to provide R1's emergency record during 911 visit. This poses a potential health, safety, and personal rights risk to persons 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20260505111640
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: HEPZEBAH HOUSE
FACILITY NUMBER: 197609871
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2026
Section Cited
CCR
87307(d)(6)
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Personal Accommodations and Services:
(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
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During today's visit the Administrator removed the hose from the front lawn. The Administrator agreed to conduct in-service trainig with all staff regarding this section. Copy of training will be submitted to LPA by POC date.
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Based on LPAs observation, licensee did not comply with the section cited above by not ensuring that the outside (front) hose is away from the ramp and properly placed/rolled on a hook. This poses a potential health, safety, and personal rights risk to persons 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5