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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609968
Report Date: 09/25/2025
Date Signed: 09/25/2025 12:15:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
07/29/2025 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20250729124550
FACILITY NAME:AFFECTIONATE CARE HOMEFACILITY NUMBER:
197609968
ADMINISTRATOR:GUZMAN, LIBRADO DEFACILITY TYPE:
740
ADDRESS:23241 VIA CALISEROTELEPHONE:
(661) 607-9624
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 4DATE:
09/25/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Librado De GuzmanTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Licensee did not issue resident’s representative a timely refund.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. LPA met with Librado De Guzman and explained the reason for the visit.

--- Licensee did not issue resident’s representative a timely refund.

It was alleged that facility did not refund at least 50 percent of the fees paid for care services for Resident #1 (R1) in April 2025 after R1’s passing. To investigate this allegation, on 07/30/2025 at around 10:30a.m., LPA requested documents and interviewed two (02) staff from 11:30a.m. to 1:00p.m. A review of the admissions agreement shows that R1 pays $6,500.00 per month and states facility will grant 50% refunds before two weeks.

(CONT. LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
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-20250729124550
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AFFECTIONATE CARE HOME
FACILITY NUMBER: 197609968
VISIT DATE: 09/25/2025
NARRATIVE
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During interviews with staff, all staff stated they were giving the family time to grieve, and responsible party is often the one to contact the facility.

Based on interviews and record reviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20250729124550
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AFFECTIONATE CARE HOME
FACILITY NUMBER: 197609968
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/25/2025
Section Cited
CCR
87507(5)(a)
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87507(5) Refund conditions. (A)Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652.
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A POC was not issued as the facility provided proof of refund.
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This requirement is not met as evidenced by; Based on interviews, facility did not issue refund timely which poses a potential health safety and personal rights risk to residents 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: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
07/29/2025 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20250729124550

FACILITY NAME:AFFECTIONATE CARE HOMEFACILITY NUMBER:
197609968
ADMINISTRATOR:GUZMAN, LIBRADO DEFACILITY TYPE:
740
ADDRESS:23241 VIA CALISEROTELEPHONE:
(661) 607-9624
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: DATE:
09/25/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:TIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Licensee did not provide resident’s representative with a final account summary.
Licensee did not return resident’s personal belongings to resident’s representative in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to the facility. LPA met with Librado De Guzman and explained the reason for the visit.

--- Licensee did not provide resident’s representative with a final account summary.
--- Licensee did not return resident’s personal belongings to resident’s representative in a timely manner.

It was alleged that facility did not provide a final accounting and inventory to formally close the care relationship and Responsible Party is unsure whether they received all of R1’s personal property. To investigate this allegation, on 07/30/2025 at around 10:30a.m., LPA requested documents and interviewed two (02) staff from 11:30a.m. to 1:00p.m. A review of the Client/Resident Personal Property and Valuables form indicates “No Valuables”.

(CONT. LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20250729124550
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AFFECTIONATE CARE HOME
FACILITY NUMBER: 197609968
VISIT DATE: 09/25/2025
NARRATIVE
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A review of a written document shows responsible party signed stating “received … rings (gold and silver w/ stone) and post-dated check for the requested refund totaling $3,250.00. . During interviews with staff, all staff stated they were given copies of all documents indicating that resident did not have valuable items. Staff added that R1 did not come to the facility with any belongings other than cloths which were returned to the Responsible Party within two days of R1’s passing.

Based on interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5