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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610040
Report Date: 01/29/2024
Date Signed: 04/14/2026 02:15:58 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
01/29/2024 and conducted by Evaluator Leslie Ngo-Castaneda
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20240129123614
FACILITY NAME:MONTARE AT THE CANYON 2FACILITY NUMBER:
197610040
ADMINISTRATOR:ALEXANDRA DECLEENEFACILITY TYPE:
772
ADDRESS:2890 KANAN DUME RDTELEPHONE:
(203) 823-8588
CITY:MALIBUSTATE: CAZIP CODE:
90265
CAPACITY:10CENSUS: 3DATE:
01/29/2024
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Denise Ojarigi, Chief Operating Officer (COO)TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Due to lack of staff supervision resident overdosed on drugs

INVESTIGATION FINDINGS:
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This report supersedes report dated on 01-29-2024 to correct the citation.

At 9:45am, Licensing Program Analysts (LPAs) Leslie Ngo-Castaneda and Angela Panushkina conducted a subsequent complaint visit to deliver the finding of the above allegation. LPA met with the Cheif Operating Officer (COO), Denise Ojarigi, and a Director of Nursing (DON), Faridah Gonzalez and explained the reason for the visit. On 01-29-2024 LPA Ngo-Castaneda conducted an initial 10-day visit. On that day LPA toured the home, conducted interviews, collected and reviewed records. During the initial visit LPA observed the medication room and the medication cabinet/cart was kept locked and inaccessible to clients in care. However, through the video footage provided by DON regarding the incident that occurred on 01/24/24, LPA observed C1 had a full access to the facility medication room through the sliding door. Also, through the video footage, LPA observed the facility did not properly store medications in a medication cart/cabinet, and it was kept unlocked and accessible to clients in care.
Conitnue to LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026
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 4
Control Number 31-AS-20240129123614
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: MONTARE AT THE CANYON 2
FACILITY NUMBER: 197610040
VISIT DATE: 01/29/2024
NARRATIVE
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The complainant concern was that the client in question was able to gain access to medications that should have been stored and inaccessible. The incident occurred on 1/24/2024 approximately 2:25 AM, when C1 was able to gain access to the medication room that was left unlocked. Once C1 gained access to the room, C1 was able to ingest medications such as: Keppra, Depakote, and Gabapentin that resulted C1 to be transferred to ICU at Los Robles Hospital.

During today’s visit (made on 02/08/24), LPAs Ngo-Castaneda and Panushkina were informed by COO and DON that during the video footage they observed S2 leaving the shift without locking the medication cabinet and or checking to see if the sliding door in the Medication Room was kept locked. LPAs were also provided with a copy of a video footage from 01/24/24 and confirmed the medication cabinet and the sliding door to the Medication Room were not locked and remained accessible to clients in care. At 12:20pm, LPA Panushkina contacted S2 and was informed that the facility had no policy of locking the medication cabinet until the incident occurred on 01/24/24. S2 also informed LPA that during the shift changes no one was told to confirm if the sliding door to the medication room was kept locked. In addition, at 12:30pm, LPA contacted S3 and S3 confirmed the fact that the facility had no policy of locking the medication cart/cabinet and or checking if the sliding door is locked during their shift changes. However, LPAs conducted review of Medication Policy and observed that “All medication shall be stored in locking cabinets or carts.” Lastly, all staff interviewed had no idea how and who left the sliding door open. Moreover, interview with S1 revealed that in between 9:30AM-10:00AM Staff #1 (S1) found C1 in their bedroom unconscious. Facility staff immediately contacted 911 and C1 was admitted to ICU at Los Robles Hospital. Medical Records (received on 1/26/24) confirmed that C1 was diagnosed with drug overdose, with no signs of acute distress, hematoma and or other injuries.

This is an immediate health and safety risk to clients in care. Based on the information gathered during the visit, the allegation is deemed SUBSTANTIATED. This is a violation that resulted in injury to resident in care. A $500 civil penalty shall be issued today however, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1548(f)(1)(a).

Deficiency cited on LIC9099-D. 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: 04/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20240129123614
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: MONTARE AT THE CANYON 2
FACILITY NUMBER: 197610040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2024
Section Cited
CCR
81078(a)
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Responsibility for Providing Care and Supervision: (a)The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidence by:
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Administrator discussed and agreed to vendorized training for all staff on care and supervision of clients. LPA is to be emailed proof of attendance and material covered by POC due date.
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Based on interviews the licensee did not comply with the section cited above by failing to have enough staff members to provide care and supervision, which poses/posed an immediate health and safety risk to clients in care, which poses an immediate health and safety risk to clients 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: 04/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4