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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610089
Report Date: 12/01/2023
Date Signed: 12/01/2023 02:56:20 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.ASC, 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
11/27/2023 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20231127125939
FACILITY NAME:FT. KNOX SUPPORTIVE HOUSING INC.FACILITY NUMBER:
197610089
ADMINISTRATOR:WILLIAMS, LAVEARNFACILITY TYPE:
735
ADDRESS:288 W TERRACE STTELEPHONE:
(323) 386-1387
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY:4CENSUS: 3DATE:
12/01/2023
UNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Latonda Knox - AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staffing at the facility was not maintained as specified by the Regional Center
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced complaint visit at this facility to investigate the above allegation. LPA met with administrator Latonda Knox and explained the reason for the visit.

LPA conducted physical plant tour at 12:30 PM, requested copies of facility documents relevant to the investigation at 1:00 PM and interview staff and administrator between 1:00 PM to 2:00 PM. It was alleged that the facility had a shortage of eighty (80) Direct Support Professional (DSP) hours for the week of 11/07/22 to 11/13/22. Based on the audit review of the San Gabriel-Pomona Regional Center, the facility only provided 232 hours which is 80 hours short based on the approved staffing level/ratio of this facility for the above stated week. Based on the information gathered during this visit, the allegation is deemed substantiated at this time.

Exit interview conducted. Appeal rights explained and issued. Copy of this report issued.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
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 2
Control Number 31-AS-20231127125939
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: FT. KNOX SUPPORTIVE HOUSING INC.
FACILITY NUMBER: 197610089
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
85065.5(a)(1)
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For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients.

This requirement is not met as evidenced by:
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Cleared during visit. The facility had complied with the Regional Center Corrective Action Plan and subsequent audits showed that the facility had complied with the DSP staffing hours.
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Based on SGP RC review, the facility was short staff during the week of 11/7/23 to 11/13/23 by 80 hrs. This poses an immediate health, safety and personal rights risk to the 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: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2