197610098-11-16-2023-31-AS-MVAO-D5WTD4-20240604143744

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610098
Report Date: 11/16/2023
Date Signed: 11/16/2023 02:35:38 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.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
11/14/2023 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20231114122645

FACILITY NAME:	AFFORDABLE BOARD AND CARE INC.		FACILITY NUMBER:	197610098
ADMINISTRATOR:	KESHISHI, VILBERT		FACILITY TYPE:	740
ADDRESS:	11382 KAMLOOPS ST		TELEPHONE:	(818) 397-5690
CITY:	LAKEVIEW TERRACE	STATE: CA	ZIP CODE:	91342
CAPACITY:	6	CENSUS: 5	DATE:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Vilbert Keshishi - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff hit resident

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 Vilbert Keshishi and explained the reason for the visit.

LPA conducted physical plant tour at 9:44 AM, requested copies of facility documents relevant to the investigation at 10:05 AM and interviewed staff, resident and resident family between 10:30 AM to 1:30 PM. It was alleged that Resident #1 (R1) was hit by a staff in the face. LPA's record review today at 11:30 AM revealed that R1 has a diagnosis of Dementia. LPA's interview with R1 today at 12:02 PM revealed that R1 was incoherent and seemed confused and was not able to answer simple questions. LPA's interview with Resident #2 (R2) who is the room mate of R1 for over a year, however, revealed that no one hit R1 nor R2 at anytime during their stay at the facility. LPA's interview with two (2) staff and administrator revealed that all of the staff interviewed denied hitting any resident at the facility at any time. (continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20231114122645

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: AFFORDABLE BOARD AND CARE INC.	FACILITY NUMBER: 197610098
	VISIT DATE: 11/16/2023

NARRATIVE

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(continued from LIC 9099)

LPA's interview with R1's family member (FM) today at 12:45 PM revealed that FM visit R1 almost everyday, sometimes multiple times a day. FM stated that it may or could have happened but did not witness any staff hitting R1 or any resident during FM's visit.

Based on the information gathered during this visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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