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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610012
Report Date: 08/02/2024
Date Signed: 08/02/2024 04:10:48 PM

Unsubstantiated


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
07/30/2024 and conducted by Evaluator Perchui Khurshudyan
COMPLAINT CONTROL NUMBER: 31-AS-20240730164145
FACILITY NAME:FAIRHAVEN HOMES VFACILITY NUMBER:
197610012
ADMINISTRATOR:MORTEL, GRACELA C.FACILITY TYPE:
735
ADDRESS:19730 KITTRIDGE STREETTELEPHONE:
(818) 727-0541
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:4CENSUS: 3DATE:
08/02/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rosemarie Santos-StaffTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff did not give medications as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Manager (LPM) Nichelle Gillyard and Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted unannounced complaint visit to the facility. LPA / LPMmet the Elsa Agustin and Rosemarie Santon and explained the purpose of this visit. Short after Assistant Administrator Christine Cheng arrived.

Allegation:Facility staff did not give medications as prescribed.

At 9.25 am LPA and LPM conducted physical plant tour. LPA/LPM interviewed the 3 clients in the home between 9:05 am and 9:25. LPA/LPA interviewed 3 staff. At 10:00am LPA/LPM reviewed client files and obtained copies of pertinent documents shich include but not limited to physician reports, IPPs, Centrally stored medicationa and destruction records.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
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 4
Control Number 31-AS-20240730164145
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: FAIRHAVEN HOMES V
FACILITY NUMBER: 197610012
VISIT DATE: 08/02/2024
NARRATIVE
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It was alleged more specifically that C1 continued taking seizure medication that had be discontinued for 4 or 5 weeks. At 9:42 am a medication review was conducted for 2 out of 3 clients. During the visit the pharmacy and C1 doctor was contacted for an interview. Both the doctor office and the pharmacy verified that there were no discontinued orders for the original seizure medication. C1 still has a standing order for the original medication and recently, an added additional seizure medication was medication. The client will be monitored and if necessary adjustments will be made according to the doctors office, however at this time the current order stands, Therefore, the allegation is unsubstantiated at this time. Facility is follow current doctors orders.

Exit interview conducted and a copy of the report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/30/2024 and conducted by Evaluator Perchui Khurshudyan
COMPLAINT CONTROL NUMBER: 31-AS-20240730164145

FACILITY NAME:FAIRHAVEN HOMES VFACILITY NUMBER:
197610012
ADMINISTRATOR:MORTEL, GRACELA C.FACILITY TYPE:
735
ADDRESS:19730 KITTRIDGE STREETTELEPHONE:
(818) 727-0541
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY:4CENSUS: 3DATE:
08/02/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rosemarie Santos-StaffTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff yelled at client
INVESTIGATION FINDINGS:
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Allegation: Facility staff yelled at client

On 8/2/2024 LPM Gillyard and LPA Khurshudyan conducted visit to the facility to investigate the allegation. LPA Gillyard and LPA Khurshudyan interviewed three (3) out of three (3) clients and the information obtained during the intervew validated the allegation and statements were made that the Staff sometimes gets fraustrated and yells at client.

The allegation is substantiated.

Exit interview conducted. Citation issued. Appeal rights and report delivered.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
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 4
Control Number 31-AS-20240730164145
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: FAIRHAVEN HOMES V
FACILITY NUMBER: 197610012
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights (a) each client shall have personal rights...(1)To be accorded dignity in his/her personal relationships with staff and other persons.

This requirement is not met as evidenced by:
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Administrator/ Licensee will ensure facility staff receive training on Personal Rights of the clients and provide a sign-in sheet of all staff that attended along with training topic(s) covered. Submit to LPA by POC due date.
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Based on interviews, the licensee did not comply with the section cited above, three (3) out of three (3) clients validated or witnessed staff member yell at clients in care, which posed a potential health, safety or 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: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4