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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610020
Report Date: 10/04/2022
Date Signed: 11/09/2022 11:09:42 AM

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
09/27/2022 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20220927165140
FACILITY NAME:MONTARE AT THE LAKEFACILITY NUMBER:
197610020
ADMINISTRATOR:DENISE OJARIGIFACILITY TYPE:
772
ADDRESS:17801 TWILIGHT LANETELEPHONE:
(760) 409-1287
CITY:ENCINOSTATE: CAZIP CODE:
91316
CAPACITY:6CENSUS: 3DATE:
10/04/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Denise OjarigiTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Facility staff is relocating clients to another location without notifying DHCS.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility. LPA met with the Administrator, Denise Ojarigi, and explained the reason for the visit.

It was alleged that staff are attempting to relocate clients to a new address without proper notification. To investigate this allegation, on 10/04/2022 at 9:30 AM, LPA visited the property located at 17801 Twilight Lane, Encino, CA 91316. LPA knocked on the door and rang the doorbell several times, but no one answered. At the time, there was no activity seen or heard on the property. At 9:50 AM, LPA contacted the Administrator and was told that all residents were relocated to 5705 Shirley Ave, Tarzana, CA 91356. LPA arrived at the Tarzana location at 10:20 AM, conducted interviews with staff from 10:40 AM - 11:10 AM and interviewed residents from 11:20 AM – 12:20 PM. During an interview with the Administrator, they stated that the residents were told verbally about the relocation, admitted that they did not notify the Department about the relocation and that the relocation was due to plumbing and other maintenance issues.
(LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
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-20220927165140
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: MONTARE AT THE LAKE
FACILITY NUMBER: 197610020
VISIT DATE: 10/04/2022
NARRATIVE
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Interviews with three (03) out of three (03) of the relocated residents confirmed that they and/or their responsible parties did not receive written notification, that they were only notified verbally with less than thirty days (30) notice and the reason for the relocation was due to maintenance issues. Furthermore, LPA conducted a record review and confirmed that a written notification was not received by the Department. Although the facility may or may not have notified the Department of Health Care Service (DHCS), the California Department of Social Services' Community Care Licensing Department can confirm that proper notification for the relocation of residents was not received. Therefore, based on record reviews, observations and interviews, the allegation is substantiated at this time. Pursuant to Title 22 Div. 6 Ch. 2 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC9099-D):

No other health and safety concerns were noted during the visit.

Exit interview was conducted, appeal rights were discussed, and a copy of report was issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20220927165140
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: MONTARE AT THE LAKE
FACILITY NUMBER: 197610020
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2022
Section Cited
CCR
81061(a)(b)(1)(E)
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Reporting Requirements (a)..licensee…shall furnish... reports as required by the Dept…(b) Upon the occurrence… of any of the events specified in Section 81061(b)(1)…, a report shall be made to the… agency within the agency’s next working day... (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
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The Licensee/Administrator will submit a letter notifying the Department, all residents and/or their responsible parties of the relocation plan which will be written according to Title 22 Div. 6 Ch. 2 code of Regulations section 81061 Reporting Requirements.
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This requirement is not met as evidenced by; Based on record review, observations and interviews, it was determined that the facility relocated residents without a written letter notifying the Dept., residents and/or responsible parties of the relocation plan which poses a potential health, safety and personal rights risk to residents in care.
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The Licensee will also review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 81061 Responsibility for Providing Care and Supervision; The written letters must be sent to the LPA by the POC due date.
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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: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3